Simplifying the Claims Process Can Help Prevent Denials

Is your facility haunted by unpaid claims? Do you have a filing system for those claims that have gone through the state level appeals process, only to end up on the wrong side of your balance sheet? Are you worried that these claims might cause your facility to fail, because they’re piling up and out of control? If you answered yes to any of the questions, then a recent idea will help – it’s a plea to simplify the process and make everything from coding to billing more transparent in the hopes that these claim denials will stop being so prevalent. Here’s how it would work.

Simplify Your Hospital’s Systems

It all starts with an integrated approach to care and test authorization. For example, if a patient needed an MRI in order to determine the cause of their back pain, in most cases, the doctor’s assistants need to contact the commercial health insurance company to get pre-approval. If it’s granted, then everything is fine, but if not, they need to jump through some hoops in order to prove that the test is needed. A simpler system would be an “integrated approach, when a physician orders an MRI for back pain, clinical and claims systems would communicate directly. If the criteria are fulfilled for doing an MRI, then the service is authorized.”

This source goes on to explain “what happens in case it doesn’t fulfill the criteria? For example, the patient has experienced the pain for less than three months and hasn’t tried certain anti-inflammatory medications. In that case, the system alerts the physician and allows them to add additional documentation or choose another care path.” This improved communication will only make things easier for the physician and the commercial insurance company, and it will hopefully lead to fewer claim denials.

In addition to this, in order “to reach this state, health care needs better collaboration. Payers and providers need to recognize areas of integration and shared goals — like happy customers and business growth. Integration begins by recognizing shared payer and provider pain points. Both payers and providers share frustrations with steps in the payment process.”

However, you might still have to deal with some claim denials.

claim denials

How You Can Avoid Claim Denials

The best thing to do is to avoid these claim denials. Many are sent back by the commercial health insurance company because the amounts are wrong, they are miscoded, or proper approvals weren’t requested and received. When the health insurance company sends back an unpaid claim, they’ll explain why. Your billing employees will need to check on this reason and find a way to correct it before resubmitting the claim.

At this point, the clinic has their billing employees send in an appeal to the health insurance company. According to current laws, there are three of these appeals available at the state level.  The insurance company then goes over the newly appealed claim denials and comes up with a new judgment. In some cases, the claim is paid. This makes everyone involved happy. The hospital no longer has to worry about that unpaid claim and they under with more money in their bank account.  In other cases, the insurance company might just pay a portion of the claim. This is called an underpaid claim. The reasons for these depend on the allowed amounts and any preapprovals – basically the same as the ones from the first round of claim denials.

On top of this, the insurance company could also keep refusing the claim outright. As we already stated, the hospital or clinic can go through three rounds of these appeals, even if the claim is underpaid. The collections process allows for this. Every time that the claim is sent back for an appeal, the odds that it will get paid go down. In some cases, the claim is partially paid and then partially paid again, leaving a balance by the end of the appeals process. Each time this happens, it costs the hospital more money and creates additional work for the billing employees.

Go Through the State-Level Appeals Process

After the three state-level appeals process is completed and the claim denials are still in place, your hospital or clinic has a choice. That money usually ends up going uncollected. It goes to your accountant’s office  where it ends up in what we call a “debt bucket.” This is a list of permanent debts on a balance sheet. The medical facility needs to make even more money to make up for this growing list of debts. Since hospitals and clinics have bills to pay so that they can stay open, this list of debts can be extremely problematic. The reason why most hospitals go bankrupt and close their doors is due to them.

Thankfully, there is a solution to getting those claim denials paid. This involves the Federal ERISA process. While many hospital administrators have heard of it, they aren’t sure about how to even begin using it.

File Federal ERISA Appeals

A Federal ERISA appeal can be filed on all of those unpaid or underpaid claim denials. The problem with this is that many of these hospital administrators aren’t sure of the process. As you can imagine, this federal process is quite complex, meaning that many billing departments don’t know how to work through it. They aren’t taught this in schools. Plus, many of the employees in those billing departments are busy either with sending out current bills or wading through state-level appeals. They just don’t have to time to figure out Federal ERISA appeals. This means that in most cases, those claim denials are written off and add to an already growing pile of debt.

What is ERISA? It stands for Employee Retirement Income Security Act. It was enacted back in the 1970s and was initially designed to protect employee retirement plans. Over time, it’s become a federal law that protects self-funded healthcare plans as well.

Essentially, the Federal ERISA appeals process is designed to get your hospital the money that it’s owed by those commercial insurance companies. Using it requires the use of a specialized billing process. It all starts with your accounting personnel. Rather than having them place your money in a debt bucket, call in a specialist. Take those claims and place them in a file.  Then call in an expert, such as ERISA Recovery. We’ll need a few things from you, including that list of claim denials and some other information. We can take it from there and will file those Federal ERISA claims for you. On top of this, we have a guarantee in place stating that we’ll recover at least one million dollars in denied claims for you within 12 months. We also don’t charge anything up front.

Healthcare Billing Commercial Appeals

We Can Help

Is your hospital or clinic burdened with commercial health insurance claim denials? You don’t want your hospital to end up going bankrupt or shutting down – not when there’s money out there that you can still collect. This is why you need to contact ERISA Recovery today. You can reach us at (972) 331-4140 or by filling out the contact form on our website. It’s time for you to move forward and take control of your hospital’s financial future!