Medical Billing and Coding Denial: Types, PR & Prevention

By Nilesh K. Shende -

 INTRODUCTION

Medical billing denials are very important and biggest challenges in Revenue Cycle Management (RCM). Claim denied means it will delay payment, increase administrative work and cost and affect the healthcare organization's revenue.
Understanding the medical billing denials and types of denials and patient responsibility (PR) helps medical coders and billers reduce claim denials/rejections and improve reimbursement.

When insurance companies refuse to pay the claim because it doesn't meet the payer's requirements. Claim may require corrections, additional information or an appeal before payment can be received. this is called denial.

Types of Denials - 

Most common types of denials are,

1) Soft Denials

Its temporary denial that can usually be corrected and resubmitted. 

Example,
 
- If modifier is missing so coders or biller may correct it or add modifiers.
- If claim found with incorrect patient demographic information.
- If authorization is missing so Physician can request.
- If document is missing then can request to department.

2) Hard Denial

Its opposite of soft denial, hard denial cannot be corrected through simple claim edits. these types of claims require appeals or cannot be reimbursed.

Example,

- If non-covered service
- When timely filling limit exceeded
- Experimental procedure
- For incorrect coding that cannot be corrected once claim submit.


  Patient Responsibility (PR)

The portions of medical expenses must pay by patient that is called Patient Responsibility.

Co-Pay - 

The co-pay refers a fixed amount the patient pays for each healthcare visit.

Example,

Dr. Visit: $500

Co-pay: $100

Insurance pays the remaining eligible amount.

Co-insurance -

It's a % of the medical bill that the patient pays after meeting the deductible.

Example,

Insurance pays - 80%

Patient pays - 20%

Deductible -

The amount, patient must pay before the insurance company begins paying for covered services.

Example,

Annual deductible - $5000
After meeting the deductible, insurance starts sharing the cost according to the policy.


There are many reasons for claim denials like, Incorrect patient demographic information's, invalid procedure codes or diagnosis codes, missing authorization, lack of medical necessity, duplicate claim submission, timely filling exceeded, incorrect modifiers and inactive insurance coverage.

Denials may prevent, verify insurance eligibility before the visit, if require, request for prior authorization, bill correct ICD-10-CM codes, CPT codes, HCPCS codes with correct modifiers, submit claim before payors filling deadlines, review documentation before claim submission, etc.

CONCLUSION

Denial Management is a most critical part of Revenue Cycle Management. If understand the types of denials and PR help healthcare providers reduce denials, improve claim acceptance and increase revenue. Regular staff training and proper coding practices are essential for successful reimbursement.



Comments

Post a Comment

Popular posts from this blog

Top 50 IPDRG Basic Questions

By Nilesh K. Shende -
INTRODUCTION Preparing for IPDRG interviews can be challenging, especially when employers assess your knowledge of PCS, Diagnosis section, sequencing rules, Guidelines and Clinical scenarios. If you are experience inpatient coder or a medical coding student or certified coder, this blog or article will help you strengthen your interview preparation. In this blog, you will find basic 50 carefully selected IPDRG interview questions with clear practical answers based on the coding guidelines. INSTRUCTION - These questions are designed for: IP-DRG interview Preparation Medical Coding Students CPC, CCS, CIC etc. Aspirants Quality Analyst (QA) Medical Coding Trainers Read each question carefully before viewing the answer. Try answering it yourself first to improve your interview confidence. 1. How will you define IP DRG? Answer: IP DRG stands Inpatient Diagnosis Related Group. It is a payment classification system that groups inpatient hospital admissions based on diagnoses, procedures, sev...
Read more

What is IPPS ? (Inpatient Prospective payment System)

By Nilesh K. Shende -
  INTRODUCTION -  Inpatient Medica Coder is an advanced coding position that is responsible for accurately assigning codes to diagnoses and procedures for all IP cases ranging from moderate to high complexity. (i.e. Trauma invasive cardiac, Multiple procedure) using current version of ICD-10-CM classification for hospitals. - The patient should stay more than 24 hours. - IPPS (Inpatient Prospective Payment System) The Inpatient Prospective Payment System (IPPS) is the payment method used by Medicare to reimburse hospitals for inpatient stay. The actual workflow of IPPS is like, Patient Admission - Physician Documentation - Medical Record Review - ICD10CM Coding - ICD10PCS Coding - MS DRG Assignment - Hospital Reimbursement.  Think of IPPS as a package-pricing system for hospital admissions. Instead of paying hospitals for every individual service, medication, test or supply used during patient stay, Medicare pays a predetermined amount based on the patient diagnosis and ...
Read more

Revenue Cycle Management Workflow | Complete Explanation with Easy Examples

By Nilesh K. Shende -
Image
  INTRODUCTION  RCM stand Revenue Cycle Management which is start when patient books as appointment and its ends when the hospital receives the full payment. so, these all workflow depends on the revenue cycle management (RCM). This RCM cycle is very important for patient, Physicians, Insurance companies, medical billers, Medical Coders, charge entry, payment posting, AR calling, Denial Management, Quality Analyst, Team Leaders, Assistance managers, Operation managers, RCM Directors etc.  This explanation is for freshes who wants to enter in medical coding or medical billing field as well as experience candidates can use for them interviews. Have you ever wondered -  - How does hospitals actually earn money after treating a patient? - Who checks the insurance? - Who prepares the medical bill? - Why do claims get denied? -  Why are thousands of medical coding and billing professionals needed worldwide? The correct answer is  Revenue Cycle Management (RCM) in...
Read more