Optimal Quality Coding Prevents Medical Claims Denials

Optimal Quality Coding Prevents Medical Claims Denials

Providers and hospitals could avoid generating significant costs from medical billing denials by improving their claims data management and optimizing their medical quality coding processes. According to the American Medical Association National Health Insurer Report Card (2013), the five most common reasons for medical billing denials include missing information, duplicated claims or services, services already being adjudicated, services not being covered by payer, and the limit for filing has already expired. Optimal quality coding effectively prevents medical claims denials. Quality coding reduces the potential for manual error and addressing concerns over fast approaching time limits.

Organizations that continuously struggle with delivering quality coding and preventing claims denials should contact YES HIM Consulting. Our team of skilled coders and auditors for their coding support, denials remediation, and other HIM services.

How to prevent future claims denials, increase reimbursement, and maximize revenue?

Quality Coding

In retrospect, many claims denials are preventable with more careful data management and improved quality coding. Even a single blank field on a claims form can be sufficient for immediate claim denial. Technical errors are responsible for 61% of initial claims denials, as well as 42% of denial write-offs. Furthermore, “duplicates, which are claims resubmitted for a single encounter on the same date by the same provider for the same beneficiary for the same service item, are among the biggest reasons (up to 32%) for Medicare Part B claim denials” (Change Healthcare, 2016).

Providers must refer to individual patient insurance policies to confirm coverage for services before seeing patients. This will avoid denial due to non-covered services, as the cost of an individual service may fall under another processed claim. Finally, with a limited window available to submit medical claims, the time-consuming process of correcting manual errors ultimately leads to unnecessary billing delays, with 81% of complex claim denials occurring as a result of expired filing limits.

Improved quality coding as a targeted strategy for process optimization

Multiple strategies exist to achieve optimal quality coding to reduce costs associated with medical claims denials and maximize revenue. Effective management of patient claims data is crucial towards this goal. Properly measure, categorize, and organize medical claims denials for efficient analysis. The quality of data entered initially upon admission must greatly improve. The creation of dedicated resources focused on continued statistical analysis of trends inpatient claims data can identify potential solutions and provide documentation of ongoing progress.

Determining the denial’s root-cause offers further valuable insight towards preventing future denials for similar reasons. Additional opportunities for improved reimbursement include the introduction of an effective denials management program. And implementation of insurance claims management software to automate portions of the claims process. Use this in combination with automated predictive analytics, and outsourcing revenue cycle management to independent, third-party consulting services.

Organizations that continuously struggle with delivering quality coding and preventing claims denials should contact YES HIM Consulting. Our team of skilled coders and auditors for their coding support, denials remediation, and other HIM services.

YES HIM Consulting

Quality Coding

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