Reducing Claims Rejections

Claim rejections are an understandable source of frustration for physicians and their office managers, since they may cause you additional work. In determining the top reasons claims are rejected, it appears that some of these rejections might be prevented through closer attention to detail in such areas as coverage, benefit limitations and referral requirements.

"What we find is that about 20 percent of claims rejections involve errors or reasons that could have been prevented on the first pass, some of them as basic as typographical errors," said Christy Ray, an account services associate. Ray noted that Humana is constantly looking for ways to cut down on rejections by modifying processes and internal procedures and using new technology. These efforts are expected to begin paying off in fewer rejections. In the meantime, physicians and their staff might find it helpful to review the top reasons for rejections below and the accompanying tips for preventing or reducing rejections.

Tips for improving claims filing and processing

1 Verify insurance coverage and eligibility prior to or at the time of service. This can be easier said than accomplished in some busy offices. But to avoid denials, it's important to confirm coverage — either online or via phone — before the service is rendered, preferably the day before the appointment. (It's advisable to go beyond merely copying the member's ID card, which may be old or expired.)

2 Check benefits and limits thoroughly. Because of the benefit-level variations among Humana products and employer groups, it helps to have a checklist at hand when determining whether a particular service is covered. Here are some questions and issues to consider:

• Is the member subject to a pre-existing condition limitation?
• Is proper authorization on file, if required?
• What limitations does this particular service have, such as maximum number of visits or annual allowable benefit?
• Does the member have other insurance?
• Is our clinic/practice a participating provider for this member?

3 Make a note of services requiring referrals and flag them. This simple system, in which referral-required services are noted on the appointment schedule the day prior to the appointment, goes a long way to reduce referral problems that could result in claims denials. After making the notation and requesting the referral, be sure to check Humana's referral look-up function on www.humana.com, or check by phone using the automated system to ensure the referral was processed. If necessary, contact the patient or the patient's primary care physician to discuss options.

4 Inquire about possible secondary/multiple insurance during patient registration. Since this question might not be part of the registration routine, consider making 3-by-5-inch cards for front office staff with a script that could be as simple as: "Mr. Jones, are you covered by any other insurance plans?"

5 Check for name discrepancies and typos before sending the claim. An extra three to five minutes can make the difference between timely claim processing and a delay or denial. For example, ensure the patient's name on the claim is the one on the ID card, not a nickname or shortened version, and double-check policy numbers, provider ID numbers, mailing address and referring physicians — and, of course, all codes and identifiers.

6 Attach medical notes when required. Some claims are rejected because the required medical notes haven't been attached on submission. Keep in mind that if the procedure code requires a modifier or the service or procedure could be considered cosmetic or possibly medically unnecessary, depending on the circumstances, medical notes should be attached to expedite claim processing and avoid rejections. As a reminder, for any CPT code that ends in "99," medical notes must be attached, since these are considered miscellaneous codes.

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