Medical billing plays a crucial role in healthcare administration, but it can be quite challenging for small medical businesses like independent labs and specialist practices. For medical practitioners, it is essential to receive timely and accurate billing to keep their offices running smoothly, receive payment for their services, and provide high-quality care to patients.

Insurance companies and government payers often deny or reject claims, creating uncertainty for practitioners about whether they are receiving fair compensation. Medical billing underpayment is a common problem that can significantly impact the financial health of medical businesses. Unfortunately, denial management is an unavoidable part of healthcare billing.

Understanding the Difference Between Claim Denials and Claim Underpayments

In medical billing, it is crucial to differentiate between denied and underpaid insurance claims during the claim cycle. “Claim denial” is when an insurer or payer refuses to pay for a service or treatment, usually due to billing errors, missing documentation, or services not covered by the insurance policy. On the other hand, “underpayment” occurs when the payer reimburses the practitioner for less than the billed amount for a service or treatment, and many reasons can lead to it.

Common Reasons for Underpaid Insurance Claims

• Coding errors, unbundling bundled procedures, downcoding, fee schedules, and policy changes are some of the common challenges that practitioners face while billing insurance companies for their services.
• Medical coding is a complex and ever-changing field, requiring a focused expertise to stay on top of all the current codes and requirements. Even minor coding errors can lead to significant discrepancies in reimbursement rates, or worse, entire claims being rejected. For instance, omitting a required modifier, which provides additional information such as which side of the body was treated or examined, can result in a rejected claim.
• Some procedures are submitted with a bundled code, which means one code includes all the parts of the procedure. However, unbundling happens when practitioners are unaware of the bundle requirement and bill each step of a procedure separately. This practice may result in higher reimbursement rates on paper, but is likely to result in underpayment if the insurer denies the unbundled claims.
• Downcoding is another common issue where insurers reimburse the practitioner for a lower-level service than what was performed. This practice is common when the insurer thinks that the practitioner is using a code for a higher-level service than was necessary for the diagnosis.
• Insurance companies have different fee schedules that dictate the amount they will reimburse for a particular service. Practitioners may receive less than the billed amount if they bill according to the wrong fee schedule or the insurer has lowered the reimbursement rates.

Lastly, insurers may update their policies and reimbursement rates, resulting in lower compensation for practitioners.

Important Steps in Claim Denial Management

There are several steps that can be taken in the billing and claims management process to reduce denied claims.

• Regularly Review Fee Schedules:It is essential to keep up with changes in fee schedules and ensure that billing is done according to the correct fee schedule, as they can vary between insurers.
• Monitor Coding Accuracy:It is important to ensure that your medical coders possess the latest knowledge and experience in coding guidelines. Regularly reviewing all claims that have issues can help identify any coding errors early on and prevent future underpaid claims caused by the repeated uncorrected errors.
• Verify Insurance Coverage:It is important to verify a patient’s insurance coverage before providing any services. Some payers may require pre-authorization for a covered service, and payment may be refused if it is not obtained prior to treatment.
• Implement a Claims Tracking System:A claims tracking system is a useful tool for practitioners to keep track of the status of their claims and detect any underpaid ones. With a good tracking system in place, you can monitor the progress of your claim submissions, rejections, and payments, making it easier for you to identify any discrepancies and take action. It is essential for the system to include follow-ups on appeals.
• Stay Up-to-Date on Insurance Policies:It is important to regularly review policies to identify changes in reimbursement rates, coverage, and coding requirements. Practitioners should review the policies of each insurer they work with, as changes will vary between them.
• Use Automated Solutions: Automated solutions like billing software and electronic health records (EHRs) can assist healthcare providers in simplifying their billing processes and reducing the chances of underpaid claims. The more your system can automate coding and billing, the lower the risk of coding errors. It is much easier for software to keep track of the correct fee schedules and submission requirements than for a human to handle all the details.
• Continually Train Your Staff:It is important to keep your certified billers informed about changes in insurance coverage and billing practices. This will help to reduce the risk of underpaid claims. To ensure that your staff is knowledgeable and up-to-date, it is essential to provide them with regular updates on the latest codes, guidelines, and insurance policies.

How to Monitor and Track Your Claims

It is important to monitor and track your claims to identify any discrepancies and take corrective action. Some effective actions that can be taken are:

• Use a claims tracking system: Such systems can help you keep track of the status of your claims and alert you to any rejected or underpaid claims, allowing you to take prompt action.
• Review billing reports: Regularly reviewing billing reports can help you identify any underpaid claims. Reports can provide valuable insights into reimbursement rates, coding accuracy, and insurance coverage.
• Follow up on claims: Make sure to follow up on unpaid or underpaid claims to identify any issues with the billing process or insurer policies. You can contact insurers to verify any discrepancies or negotiate for fair reimbursement rates.

Filing Appeals Is a Regular Part of Healthcare Underpayment Recovery

It’s important for healthcare providers to appeal any underpaid claims to receive fair compensation for their services. However, figuring out the reason for the underpayment and correcting it may take some time, which is why many claims are abandoned when they are denied. To avoid this, it’s recommended that you proactively appeal any underpayment that you disagree with. While some services may not be covered by the payer, there are some common situations where you should appeal, such as when the insurer underpays due to incorrect coding or fee schedule errors, denies coverage due to incomplete information or lack of documentation, downcodes a service or procedure that was necessary, or fails to pay for covered services.

The Appeal Process: Tips and Strategies

Appealing underpaid claims can be a challenging and intricate process. To help you, here are some tips and strategies that you can use:

• Familiarize yourself with the insurer’s appeals process, including the timeframe for filing an appeal, the required documentation, and the steps involved in the process.
• Gather all necessary documentation, such as medical records, coding information, and insurance policies. Having this information readily available can help speed up the appeals process.
• Make a compelling case for your appeal by providing evidence of the services rendered, the necessity of the services, and the correct coding and fee schedules used.
• Following up on your appeal can help ensure that the insurer receives and processes it promptly.

Negotiating with Payers for Fair Reimbursement Rates

Negotiating fair reimbursement rates with payers is an essential aspect of medical billing that requires some skill. To help you with this task, here are some tips for negotiating effectively:

– Know Your Value: You must understand the value of your services and the costs associated with providing those services. Having a good understanding of your costs can help you negotiate better reimbursement rates for complicated procedures.

– Research Reimbursement Rates: Research reimbursement rates for your specialty in your local area to ensure that you are receiving fair compensation.

– Be Prepared: Come to negotiations prepared with documentation to support your case, such as data on your costs and expenses. Having this information readily available can help you make a strong case for fair reimbursement rates.

– Be Assertive: Be confident and assertive in your negotiations, making it clear that you are seeking fair and reasonable reimbursement rates.

– Consider Outsourcing Medical Billing: Outsourcing medical billing can provide practitioners with access to billing experts who have experience negotiating with payers.

The Benefits of Outsourcing Healthcare Claims Denial Management

Managing denied claims can be time-consuming and requires specialized skills. Outsourcing denial management as part of your medical billing process can provide several benefits, such as reduced administrative burden, improved cash flow, increased efficiency, and access to billing experts.

By outsourcing medical billing, practitioners can free up their time from administrative tasks and focus on delivering quality care to their patients. Additionally, having your medical billing handled by experts can improve cash flow by reducing the time it takes to submit claims and deal with any rejections and denials.

Medical billing companies have experience and expertise in coding accuracy, insurance policies, and reimbursement rates. Outsourcing medical billing increases efficiency and reduces underpaid claims. Moreover, medical billing companies have a team of billing experts who can negotiate with payers and secure fair reimbursement rates, ensuring that medical businesses receive fair compensation for their services.

Ensuring Fair Payment for Your Services

Accurate and timely medical billing is crucial for medical businesses to receive fair compensation. Underpaid claims can significantly impact a medical business’s financial health, so it’s essential to identify and address them promptly. Any medical billing company should take responsibility for following up on underpaid claims to maximize revenue for their clients.

Implementing best practices such as regularly reviewing fee schedules, monitoring coding accuracy, and appealing underpaid claims can help reduce revenue loss. Outsourcing medical billing provides many benefits, including increased efficiency, cash flow, and access to billing experts.