Question 1

Why are my claims being denied?

Accepted Answer

Claims can be denied for various reasons including incorrect patient information, inaccurate coding, lack of medical necessity, or insufficient documentation. It’s crucial to review the denial reason provided by the payer and correct any errors for resubmission

Question 2

How can I reduce the number of claim denials?

Accepted Answer

Reducing claim denials begins with implementing thorough checks before submission. Ensure that coding is accurate, patient eligibility is verified, and all necessary documentation is attached. Regular training for staff on the latest billing practices and payer policies is also essential.

Question 3

What is the difference between a rejected claim and a denied claim?

Accepted Answer

A rejected claim is one that has been processed and returned by the payer due to a fatal error or omission, often before it is entered into their system. A denied claim is one that the payer has processed and determined to be unpayable based on their rules or coverage policies

Question 4

How often should I follow up on unpaid claims?

Accepted Answer

It’s best practice to follow up on unpaid claims at least every 30 days. Regular follow-ups ensure that any issues are addressed promptly and help maintain steady cash flow.

Question 5

Can I bill a patient for a service that their insurance has not covered?

Accepted Answer

Yes, you can bill a patient for services not covered by their insurance, provided that the patient was informed about the likelihood of non-coverage and agreed to be financially responsible, typically documented through an Advanced Beneficiary Notice (ABN).

Question 6

What is a clean claim?

Accepted Answer

A clean claim is one that has no defects or improprieties, requiring no additional information to process. It is accurately completed and fully compliant with the payer’s policies, hence it gets processed and paid promptly.

Question 7

How can I keep up with the constant changes in billing regulations?

Accepted Answer

Keeping up with changes requires ongoing education and vigilance. Subscribe to industry newsletters, attend webinars and workshops, and participate in professional forums. You can also consider partnering with a billing service that stays updated on regulatory changes.

Question 8

What are the most common coding errors that lead to claim issues?

Accepted Answer

Common coding errors include using outdated codes, incorrect use of modifiers, upcoding, unbundling, and undercoding. Continuous training and using updated coding resources can help prevent these errors.

Question 9

How do I ensure compliance with HIPAA in my billing processes?

Accepted Answer

Compliance with HIPAA requires safeguarding patient information through secure systems, ensuring only authorized access, providing regular staff training, and staying updated on HIPAA regulations. Conducting regular audits can also help maintain compliance.

Question 10

What should I do if I notice a pattern of certain types of claims being denied?

Accepted Answer

Investigate the commonalities among the denials to identify the root cause. It could be a specific coding issue, payer policy change, or an internal process error. Once identified, take corrective actions such as staff retraining, process adjustments, or direct communication with the payer for clarification

AI & Generative AI Transforming US Healthcare Operations

Navigating the Future: AI & Generative AI Transforming US Healthcare Operations

Key Market Insights (2025–2030)

Challenges in Operations

THE AR > 90 DAYS ZERO IN US HEALTHCARE RCM

EFFICIENT AR MANAGEMENT

THE NEED FOR RCM OUTSOURCING

INHOUSE VS OUTSOURCED MEDICAL BILLING

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