How can you improve your revenue cycle management process to reduce claim rejections?

1 Verify eligibility and benefits

One of the most common reasons for claim rejections is incorrect or incomplete information about the client's insurance coverage and eligibility. To prevent this, you should verify the client's eligibility and benefits before providing the service or product, and update your records accordingly. You can use online tools, phone calls, or faxes to check the client's insurance status, plan details, copayments, deductibles, and prior authorizations. You should also confirm the client's personal and demographic information, such as name, address, date of birth, and social security number. By verifying eligibility and benefits, you can avoid claim rejections due to mismatched or missing data, and also inform your clients about their financial responsibilities and expectations.

2 Use accurate and compliant coding

Another common reason for claim rejections is inaccurate or non-compliant coding of the services and products you provide. Coding is the process of translating the clinical documentation into standardized codes that represent the diagnosis, procedure, or modifier of the service or product. Coding errors can occur due to human mistakes, outdated codes, insufficient documentation, or lack of specificity. To prevent this, you should use accurate and compliant coding that follows the guidelines and rules of the payer and the coding system, such as ICD-10, CPT, or HCPCS. You should also review and update your coding regularly to reflect the changes in the industry and the payer policies. By using accurate and compliant coding, you can avoid claim rejections due to invalid or incorrect codes, and also ensure that you capture the full scope and complexity of the service or product.

3 Review and scrub claims

Another common reason for claim rejections is incomplete or inconsistent information in the claims forms. Claims forms are the documents that you submit to the payer to request payment for the services and products you provide. Claims forms errors can occur due to typos, omissions, duplicates, or discrepancies. To prevent this, you should review and scrub your claims before submitting them to the payer. Reviewing is the process of checking your claims for accuracy, completeness, and consistency. Scrubbing is the process of correcting or removing any errors or inconsistencies in your claims. You can use software tools, checklists, or external services to help you review and scrub your claims. By reviewing and scrubbing your claims, you can avoid claim rejections due to incomplete or inconsistent information, and also improve your claim submission efficiency and quality.

4 Track and follow up claims

Another common reason for claim rejections is delayed or missed communication with the payer. Communication is the process of exchanging information and feedback with the payer about the status and outcome of your claims. Communication errors can occur due to technical issues, lost or misplaced claims, or lack of response or acknowledgment. To prevent this, you should track and follow up your claims after submitting them to the payer. Tracking is the process of monitoring your claims for receipt, processing, and payment. Following up is the process of contacting the payer to inquire about any issues, delays, or rejections of your claims. You can use software tools, reports, or dashboards to help you track and follow up your claims. By tracking and following up your claims, you can avoid claim rejections due to delayed or missed communication, and also resolve any issues or disputes quickly and effectively.