By: Kristen LaPlante, Reimbursement Supervisor, WellSky
As home infusion reimbursement margins continue to run lean, your organization needs to collect on every service provided, in full. But no one is perfect and claims get denied — even when your billing team did everything right. After a denial, it’s important to log and track the denial frequently so your business can understand the source of the issues and improve internal training and billing practices.
Use these six tips to help you log, track, and analyze denials, so your business can improve cash flow and reduce write offs and adjustments.
- Understand why logging denials is important. Many pharmacies may be out of practice when it comes to logging denials. Although no one looks forward to seeing denials, it’s important to log the reasons for the denials in your software system as soon as you receive them. Taking time to log the correct reason (e.g. missing documentation, missing physician signature, etc.) will help us understand if contract terms have changed with a payer for example and this is an external issue, or if staff need more training where this would be an internal issue. You cannot track and monitor what you can’t see, so the first step is inputting this information your software system correctly.
- Know that not all denials are bad. It’s important to remember that most home infusion therapies are not covered by Medicare, and that a secondary insurance is needed. Blue Cross is an example. In this case, you will receive an “expected denial,” which is a good denial that the secondary insurance knows to pay.
- Logging denials prepares you for accreditation. For accreditation from the Joint Commission on Accreditation for Healthcare Organizations (JCAHO), your pharmacy must provide a monthly report of Medicare unexpected denials to show you are working on the denials and the current status in resolving these. Using ZirMed to track denials is also a great tool to share this information with internal and external stakeholders in a consistent format.
- Automating your processes can save time. Rely on automated reporting to learn why a claim was denied instead of spending precious time tracking paper remits. Going paperless not only saves time, but it can also help you get to the root of the issues much quicker. Depending on your software system, reporting tools allow you to see your unworked denials in one place and then go to the specific payer website to resolve the claim within minutes. Easily identify claims that need to be appealed for a specific denial reason and sort data by insurance carrier instead of sorting through each individual claim in question. Mediware’s reporting tools allow pharmacies to set up reports that run on your timetable. With Mediware’s advanced reporting capabilities, your billing staff, reimbursement managers, and operations staff can all receive timely reports automatically.
- Identify trends and learn from them. Avoid working in silos where communication is limited and learnings are not shared across members of the billing team. Working together improves your team’s billing knowledge and encourages staff to follow a consistent process. Here is an example of a scenario to avoid: Four billing team members are processing claims for a certain payer and have consistent denial errors. Instead of running a trend analysis report of all denials categorized by denial reason, they treat each claim as a separate issue. We miss key learnings are missed when we don’t have our billers and reimbursement managers review trends in our denials. In this case, we could have easily seen that a payer changed their requirements to now include an authorization with the claim, but not all team members knew about the change. Talking about issues from a global perspective not only gets to the issues sooner but also prevents rework on claims that were billed incorrectly. Because payer contract terms, regulation changes, and billing requirements are always subject to change, make sure your billing team is proactively staying a step ahead of these changes.
- Work denials within timely filing limits: After logging the reason for the denial in your system, it’s time to determine what you need to resubmit the claim within the timely filing guidelines. Working backward from the timely filing limit is a great way to make sure you have enough time to capture missing information, gather physician signatures, etc., so you can resubmit by the deadline. A best practice for managing denials is to work them within seven days or less. It takes an average of 60 to 90 days to resolve a denial, so keeping track of the calendar is always a good idea.
Logging denials is an important step in your reimbursement process. It provides insight into why claims were denied, what you can learn from mistakes, and how to continue billing correctly in the coming months. For assistance on home infusion and DME billing, WellSky’s reimbursement services team works with you to ensure you can collect on your services. WellSky’s proven results help businesses lower bad debt, grow cash-to-net-revenue, and lower days sales outstanding (DSO).
Learn more about how WellSky’s reimbursement services can support your billing processes.
