American Academy of Pain Medicine stated that millions suffer from acute or chronic pain every year in the US, and the effects of pain exact a tremendous cost, billions of dollars, each year. As the population ages, these numbers are expected to grow — incidents of long-term pain from arthritis, neurogenic or other age-related conditions.
Despite the huge demand, over the past years, new state and federal regulations, scrutiny from payers trying to keep costs down by expanding prior auth requirements, downward adjustments to fee schedules, and trends like value-based reimbursement and healthcare consumerism have brought some unique challenges that affect pain management practices.
Why are the claims denied?
After analyzing the electronic health records (EHR) of a pain management group using the proprietary AI-based solution HealthX our revenue cycle management (RCM) experts identified major roadblocks to successful claims. Here are some of the instances when the claims are rejected or denied:
- Denials for Durable Medical Equipment (DME) billing due to ICD/ CPT mismatch.
- Radiofrequency Ablation (RFA) denials as they exceeded the year’s permissible frequency.
- Urine Drugs Screens rejections as Aetna pays only 8 times a year.
A report by AARP goes on to confirm the veracity of growing rejects in medical claims, such as in the above findings. “One in seven of all claims get denied, amounting to over 200 million rejections each day”.
How does then a practice reduce claims denial rate? The answer lies in streamlining claim denial management.
Overcoming major revenue cycle challenges by
Creating a streamlined procedure for claims tracking
You can address and resubmit a claim denied, or EDI rejected claim if you’re following a streamlined process. In its absence, you’re likely to take time to identify the claim and find a relevant resolution, all of which means a delay or worse a dent in cash flow.
Finding out the right reason behind denials
Did you know? Medicare pays approximately $40 for a vitamin D test (CPT 82306). If a practice facilitates this medical necessity but receives denials 30 times a month, that’s $14,400 a year. You may need to fix coding errors or perhaps find the right modifier — to upgrade the rate of cleaner claims. Modifiers exist to clarify the service or procedure done and can make a significant impact on revenue.
Example:
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LT
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Anatomically left
|
|---|---|
|
RT
|
Anatomically Left
|
|
50
|
Bilateral
|
|
59
|
Independent procedure or service from the ones performed on the same day
|
|
53
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Incomplete procedure- the physician ends a procedure for the patient's well-being
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Enhancing claim scrubbing capacity
It’s the process of scanning your practice’s medical claims for errors that could cause insurance companies to deny the claim. This viably helps diminish the number of claims that are rejected and can help you save huge resources, more money, and time.
Ensuring clean claims ratio; Higher than 98%
Submission of clean claims is an important component of a financially successful medical practice. The term “clean claim” in medical billing refers to claims, forms, and fields that have been filled out accurately and in compliance with legal policies. At Jindal Healthcare, we maintain a clean claims ratio of 98% for our partners.
Final Thoughts
Our best chance to get paid sooner and accurately is on the initial submission. However, several claims are denied [and sometimes EDI rejected], citing medical necessity, often due to an ICD/ CPT mismatch. For example, SCS trials- CPT 63650 should always go out with a secondary ICD, and yet something as expensive gets billed out without the supporting ICD. Therefore, it’s now more important than ever to ensure a state-of-the-art revenue cycle management process that streamlines claim denial management to improve clean claims ratio, increase the net collection rate, identify revenue leakage, and underpayments.
An alternative is to consider engaging a third-party partner who has the expertise to code and bill efficiently and scale without issue and maintain the training and updating required to stay in top form. If you’re understaffed and losing revenue, consider engaging a third-party partner, an efficient revenue cycle management specialist, who can streamline the claim denial management process for your pain group. Learn how experts at Jindal Healthcare can help avoid denials and accelerate reimbursements.
