Accurate claim submission is one of the most critical phases of the healthcare revenue cycle. Inaccurate submission of claims can lead to denial, payment delays, and rework. Frequent issues occur at this stage in most practices without even being aware of how easily they can be handled by better systems or by choosing to outsource claim submissions to experienced professionals.
The Top Problems in Claims Submissions
1. Inaccurate or Incomplete Patient Information
Inaccurate or missing patient data is perhaps the most common cause of claim denial. Misspelling a patient’s name, insurance ID, or demographic data can be minor but cause immediate claim denial. Avoid this by ensuring that your front-desk and billing personnel verify all patient data with every visit. Using automated verification software or a checklist will ensure that every field has been correctly verified before release.
If your employees handle large volumes of claims on a regular basis, it may be a good idea to outsource claim submission. Professional billing personnel go through several checks before submitting claims, reducing the chances of human mistakes and rejections.
2. Coding and Documentation Errors
Inappropriate coding remains the biggest hindrance in medical billing. Coding mistakes can delay payments or even trigger audits. It’s imperative to have certified coders check documentation before submission. Additionally, having a systematic claim edit process can detect differences between codes and documentation.
Claim scrubbing software identifies inconsistent codes, missing modifiers, or erroneous combinations before transmitting the claim to the payor. Proper management by this process saves a significant amount of time and prevents unnecessary denials.
3. Insufficient Claim Scrubbing Practices
Claim scrubbing refers to the review of claims for accuracy and compliance prior to submission. Unfortunately, due to older systems or not prioritizing it because of lack of time and staff, many practices do not scrub. Claim scrubbing is thorough, meaning it identifies issues, including invalid codes or payor requirements.
4. Payor-Specific Rules and Frequent Policy Changes
Every payor has unique claim submission rules. Even slight deviations can result in denials if not followed. Keeping tabs on these constantly shifting rules is a serious headache for most in-house employees.
Partnering with a professional billing company like RCM Workshop to outsource claim submission can be a huge game-changer in this area. The billing experts specialize in staying current on payor policies, handling tracking compliance, and responding rapidly to rule changes, so your claims remain compliant with each payor’s rules.
5. Missed or Delayed Submissions
Missing filing deadlines is another expensive error. Payors tend to have strict timeframes, and one lost filing date can mean lost revenue. Having automated reminders and work queues can assist your billing staff in monitoring pending claims. With outsourcing, service providers typically offer submission tracking devices that indicate pending claims in real time, minimizing lost revenue.
6. Failure to Follow Up after Submission
Half the battle is in getting a claim submitted. Most practices are losing money because they don’t track claim status or follow up on denials in a timely fashion. Continuous monitoring ensures unpaid claims are adjusted and resubmitted immediately. If your employees are having a difficult time with this, you may want to consider adding claim tracking dashboards or contract follow-up for external staff that is trained in end-to-end billing management.
Successful claim submissions rely on compliance, timeliness, and accuracy. The combination of outsourcing with work excellence prevents common pitfalls of inaccurate data, bad scrubs, and missed deadlines.
Outsourcing claim filing to experts like RCM Workshop gives you the opportunity to leverage experienced professionals who correctly do the claim edit and claim scrubbing, leading to payments being received sooner and claim denials being reduced. With clean claims walking out of your doorstep earlier, your practice can enjoy a healthy cash flow and spend more time on patient care and less on paperwork.
