|MCOs Utilize Prevention And Education To Limit Denials
Payments for submitted claims are an everyday battle for most healthcare organizations, according to a survey by the Managed Care Information Center; MCOs believe in due diligence as prevention and react to denied claims with education.
The "Managed Care Leadership Survey On Managed Care
Claims Payments" found MCOs err on the side of caution when it comes to
seeking reimbursement, double checking to verify coverage before
"We attempt to head off issues prior to sending the
claims by verifying information prior to patients being seen," said the
billing manager of an IPA. "This does not always fix the issue but does
seem to help even though it is more work on the physicians side of
getting claims paid."
Another member of an IPA said, "We verify at every visit
... even then we get retro denials due to people being dropped from
plans," said the practice administrator.
There is no doubt among those surveyed that a relationship with the companies they submit claims to is necessary.
The director of managed care at a hospital/medical
center said, they are "working on a manual listing by insurance company
on all procedures requiring authorizations. Also working with vendors
to appeal denials – especially inpatient ones. It is becoming
harder to get the appropriate payments from insurance companies and
patients. As the deductibles and co-pays increase, so does the bad debt
incurred by the health care providers ... to get their fair
Other than reaching out to ensure payment, MCOs are using previously denied claims to learn from.
The claims manager from an MCO will "analyze an internal
report of denials by the provider and contact the providers in our
network with a sizeable volume of denials to assist and educate in
claims filing issues."
The assistant vice president of an MCO collects the
denials and identifies them. After they are identified by the reason of
rejection, they are then categorized by: provider education issues;
denials due to changes in a federal or state mandate, to billing
guidelines, or to codes; and system issues, etc.
After they are then separated by denial factors, the
assistant vice president can begin to set forth education solutions to
help providers better understand where they are faltering and how to
correct their common mistakes.
Besides education through the use of past claims and
utilizing audits, MCOs are employing other techniques to reduce claim
One consultant from an MCO is increasing auto
adjudication to offset the denials and John Dent, a provider network
consultant is focusing on introducing Web tools and making them aware
Providers should take advantage of the Web tools, but
they are "reluctant for a host of reasons to fully utilize payor Web
tools, which makes this process much quicker and a more efficient use
of staff time and technology," said Dent.
Another effective solution the manager of case
management at a hospital/medical center gave was to increase the
manpower by hiring more full-time employees to ensure compliance on the
Address: Health Resources Publishing, Managed Care
Information Center, 1913 Atlantic Ave., Suite 200, Manasquan, NJ 08736;
(732) 292-1100, www.healthresourcesonline.com.