Value-based care is about empowering both the healthcare provider and their patients by creating flexibility, improving communication about medical health, and financial transparency. When the healthcare providers reduce administrative paperwork burden and alleviate patients’ financial stress by minimizing the claims denied by insurance providers it offers a win-win situation for everyone involved. 

Unfortunately, physician practices still continue to see claim denials as high as  20%  from both commercial and private payers. Practices that continue to have challenges with avoidable rejected claims will diminish their revenue greatly, therefore potentially causing the demise of the practice. Most claims are completely preventable with a few foundational changes to the medical coding and billing practices of your office. 

Ensuring Prior Authorization 

Insurer policies, coding, and medical requirements on approved treatments, procedures, testing, and medications change from month to month, sometimes on a weekly basis. Ensuring that your billing administrator has a prior authorization process that is done for all patients regardless of whether they are new or regular patients. Some of the most common reasons for claim denial stems from: 

• – Incorrect coding
• – Missing pre-certification
• – Missing or incorrect information
• – Missing a filing deadline

There are other common reasons but making sure that processes are in place can drastically improve the outcomes of the claims submitted. 

Determine the Cause of the Denials

Repetitive mistakes need to be determined by tracking and analyzing the data. Auditing and analyzing the information that leads to the claim rejection is the first step to understanding why they keep occurring. Gathering information like:

• – Rejections coming from a certain set of payers
• – The type of rejections that are taking place
• – The volume of denied claims

Business intelligence tools and having a full-time staffing person to manage this can be costly, and partnering with a company like BrightDrive Healthcare Solution can be the best long-term and cost-effective solution. 

Increasing Communication

Miscommunication between the medical administration and payers tends to be the next leading cause of claim denials. The medical coding management staff may assume what is needed for the payer based on incorrect or outdated information or there could be a misunderstanding of why a particular claim has been denied. Increasing the communication between the medical office and vendor will help build the necessary relationships needed to keep communication ongoing.  Building relationships with vendors takes time but when you align your organization with a company like BrightDrive HCS, who already works closely with these payers, the time for relationship building is lessened. 

Improving the overall workflow

Medical business audits are necessary to improve workflow inefficiencies. When was the last time tasks and resources were analyzed in your practice? To aid in value-based care, the key for minimizing administrative burn-out and increasing patient satisfaction is about understanding what solutions are needed to be built into the foundation of the organization. 

Complete an Attestation

According to a recent study, hospitals and other medical facilities are facing somewhere between 5% to 20% potentially avoidable claim denials. Successful attestations required strict adherence to medical guidelines and be performed in a timely manner to even be considered effective. Physician medical practices will need to stay up-to-date in order to remain an eligible provider with CMS to continue to be compliant and eligible for attestation. 

Conclusion

Physician medical practices can make simple changes within the office that will financially benefit the practice in the long run. These changes will only happen when the issues are identified and fixed immediately, and working in collaboration with an organization like BrightDrive HCS, which specializes in audits and payer arrangements, is the key to your organization’s success. 

Eliminating financial stress from the patient and decreasing the paperwork burden from the administration is all a part of value-based care. Begin the process of improving efficiency, increasing quality of service, meanwhile creating better risk management and financial growth opportunities for your practice. 

Learn more about how  BrightDrive Healthcare Solutions Medical Management Services can help reduce claim denials and increase compliance with your physician practice. We have contracts with a multitude of providers, allowing you the opportunity to be connected with even more commercial providers. Contact us today!