Keeping rejection rates as low as possible is important (5% or less; I used to say 3%, but payers often reject for no reason banking on the fact that you are too busy to follow up)
The #1 reason for rejection continues to be SIMPLE HUMAN ERROR so train your staff to be diligent in their attention to detail. This includes:
- • Accurately inputting patient names (exactly as listed on insurance card)
- • Repeating back names (never assume spelling), dates of birth, insurance ID numbers and best phone numbers to reach and remind of their appointments
- ○ The first time patients are seen each year have them verify that all demographic information is the same (or not) and take a new scan of the front AND back of the insurance card (payor IDs can change if all else stays the same).
- ○ Patients should be reminded at the time of appointment confirmation that this information will be collected. If a new insurance will be in effect as of January 1st, we must collect the ID# ahead of visit to verify coverage and review benefit details. This helps us to adhere to our own financial policies (which should be updated each year).
- ‣ Better yet, work with your website provider to incorporate HIPAA compliance plugins and have patients upload insurance information (actual scans of their cards) along with photo IDs.
As just mentioned, at minimum, you must verify that patients have active coverage at each and every visit (from there you can find benefit details such as copay, deductible and how much has been met, plan carve outs, etc.). Reschedule patients or offer a cash pay fee schedule rather than let inactive coverage be a reason for denial.
- • If you are not able to see benefit details through your EHR/PM system, someone on your staff should be calling insurance companies or checking payer portals.
- • Even if the details are difficult to decipher, we should at least know the basics (copay, deductible, how much has been met, etc.)
Above all else. . . Avoid Dumb Denials
- • Consistently check for claims stuck in “user hold” for reasons that could be resolved in a matter of minutes (DLS and/or PCP not listed)
- • Train your staff to ask EVERY Medicare and Medicare Replacement/Advantage patient at EVERY visit to verify the name of their PCP and when they were last seen there (then make sure this information is entered appropriately so it populates on the claim)
- • If you do not know where this information needs to be entered, find out and then make sure every member of your staff knows too!
- • If you are in a region where RFC patients do not have a PCP and see only NPs and PAs, this poses additional coverage issues which need to be discussed with your billing team and patients.
Additional Resources
Pinnacle Practice Achievement (PPA) is a consulting firm dedicated to coaching podiatrists and their team members nationwide. For more than two decades, President, CEO, and lead consultant, Cindy Pezza, PMAC has immersed herself in the rapidly changing landscape of podiatric practices as well as the need to continuously evolve the methods in which they are managed. In working with Pinnacle Practice Achievement (PPA) providers are able to utilize Cindy’s expertise and select a program that works best to fit their needs. PPA offers what practices require the most to survive and thrive in the ever-changing world of specialty healthcare.
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