Revenue cycle management faces the problem of denied claims in the sense that the entire processes involved with cardiology, not to mention insurance, entail complicated steps whereby an little mistake leads to either denial of or delayed processing of payments. In such respects, denied cash flows add increased administrative burdens. As a result, all health providers are frustrated and disgruntled among themselves.
Knowing the most common causes of claim denial and implementing proper denial management will help cardiology practices reduce losses and maximize reimbursement rates. The following article examines these causes and provides actionable solutions to address them.
1. Incomplete or Incorrect Patient Information
Why It Happens:
Simple name, date of birth, or misplaced insurance information mistakes will result in immediate claims denial management. In many instances, these happen because the patient’s data was not updated and verified when a service was received.
How to Correct It:
- Always perform eligibility and benefits verification every visit.
- Train front-desk staff to check patient details against the insurance record.
- Use electronic verification tools to decrease the possibility of errors due to humans making mistakes.
2. Lack of Prior Authorization
Why It Occurs:
Most cardiology services, including stress tests, echocardiograms, and catheterizations, need prior authorization from the health plan. Without getting permission, these services are rejected automatically.
How to Correct This Condition:
- Standardize a workflow for obtaining prior authorization before scheduling procedures.
- Keep a list of cardiology services that need prior authorization from other insurance firms.
- Identify specific people who will receive and follow up on authorization requests.
3. Coding Mistakes and Poor Documentation
Why It Happens:
Cardiology medical coding is complicated, with frequent updates on CPT and ICD-10 codes. Some of the common mistakes made in coding include:
– Application of obsolete or wrong codes.
– Lack of inclusion of modifiers that are obligatory.
– Inappropriate linking of diagnosis and procedure codes.
How to Fix It:
– Give regular training for the coders and billing staff in cardiology coding latest guidelines.
– Use advanced billing software that has auto-code validation.
– Perform routine audits, catching coding mistakes that would be accurate had they been corrected before submission.
4. Medical Necessity Denials
Why It Occurs:
The insurance company denies a claim when it determines that a procedure was not medically necessary. This occurs when the diagnosis submitted does not warrant treatment according to the payer’s guidelines.
How to Correct It
- Physicians must give complete documentation on what makes the procedure medically necessary.
- Use a specific ICD-10 code directly related to the symptoms or condition being treated.
- Educate your staff on payer-specific policies about medical necessity requirements.
5. Duplicate or Overlapping Claims
Why It Happens:
Claims can be denied when they appear as duplicates in the insurer’s system, often due to resubmissions without proper tracking. Overlapping claims also occur when multiple providers bill for the same service within a short timeframe.
How to Fix It:
– Track claims to avoid overbilling.
– Keep proper documentation, especially if multiple providers have served clients for different services.
– Properly code the claim with different service dates and different provider identifiers.
6. Filing Too Late
Why It Happens:
Every insurance company has a claim submission deadline, and the deadline can vary from 30 to 180 days. After the deadline passes, claims get automatically denied.
How to Fix It:
- Monitor particular deadlines for submitting each payer claim and create reminders for upcoming cut-off dates.
- Establish a streamlined claims submission process to avoid delay.
- Implement an electronic claims submission process to speed up the process and monitor the status of claims, if required.
7. COB Issues
Why It Happens:
The most common problem encountered with patients with multiple insurance plans is COB, which arises when the primary and secondary payers cannot agree on who pays first.
How to Fix It:
- Obtain the patient’s insurance coverage and COB status before filing a claim.
- Format claims properly so that both the primary and secondary payers can be indicated.
- Follow up on the discrepancies regarding COB by contacting the respective insurance providers.
Proactive Denial Management for Better Financial Health
Only if the practices remain financially healthy can claim denials be reduced. Eliminating missing information, authorization problems, and coding errors commonly resulting in denial can improve the rate of approved claims and revenue cycles.
Using proactive strategies such as automated eligibility verification, proper documentation, and regular staff education will likely result in fewer denials and expedited reimbursement processes. In addition, keeping abreast of payer-specific guidelines and outsourcing to specialists can further improve denial management performance.
By these measures, the cardiology practices will ensure seamless operations, positive financial performance, and positive patient care.
