ICD-10 was more complicated and precise than its predecessor, but the transition presented seemingly calm waters for many healthcare providers when the coding grace period was lifted late in 2016. But even more change is on the horizon with the World Health Organization’s upcoming release of ICD-11, which will have a pronounced impact on coding and medical billing. Therefore, if you’re experiencing any challenges with post-bill denials (and it’s likely you are since, on average, 9% of all provider claims are denied with a total annual cost of $262 billion), now is an opportune time to address them before working through a new set of medical codes.

One of the easiest ways to lessen the medical claim denial burden is to focus on denial prevention via your pre-bill claim review process. Much like a beach umbrella prevents a sunburn, focusing on pre-bill claims means avoiding denials – which positively impacts your bottom line and allows you to focus on providing better care. To help you prevent as many post-bill denials as possible, consider these three steps in order to improve your existing processes.

1. Determine and Address Claim Denial Root Causes.

The best place to start is figuring out your denial root causes. There are many different places throughout the care and billing cycles where errors can occur, so it’s a good idea to take a look across the board. Here are some places that errors leading to denials commonly occur:

  • Patient data entered incorrectly upon registration.
  • Lack of medical necessity for care provided.
  • Checking benefits eligibility.
  • Wrong or insufficient documentation.
  • Improperly coding.

Medical claims review technologies are available to help search your existing data to find medical record information pertinent to a claim.

2. Train All Staff and Physicians.

One healthcare provider, Baptist Health South Florida, was able to reduce the impact of switching to ICD-10 through training everybody involved in the revenue cycle, from physicians to coders. For example, they handed the coding books to their physicians and let them know that proper training was available, if they were curious. This process helped physicians that weren’t especially engaged in this process understand the importance of complete, relevant documentation.

It’s also important to ensure that training is continuous. As we discussed above, you should be constantly reviewing and analyzing your denials. As new data comes to light, you’ll want to update your training materials and provide updated information to any necessary clinical staff.

3. Focus on Pre-Bill Processes to Prevent Denials.

Throughout your pre-bill claim review process, it’s important to focus on more than just avoiding denials. Make sure that everything is coded properly for all the care provided to ensure that you aren’t underpaid. It’s also just as important to ensure that you’re not going to get overpaid. Thanks to Medicare’s 60-day overpayment rule, you could be on the hook for fines for any self-identified overpayments that aren’t reported within 60 days.

Clear Skies Ahead with Advent’s Denial Prevention Team

Reducing post-bill denials is an arduous, continual process, and there’s no single magic solution. However, by following these tips and tricks, you’ll have a much stronger grasp on the process and should realize tangible results quickly. By the time ICD-11 rolls around, you’ll be ready to hit those waves.