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Home / News & IndustryManaged Care Insight and Analysis
Updated: June 22, 2010
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 administering services.

"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 reimbursement."

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 denials.

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 of theireffectiveness.

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 front lines.

Address: Health Resources Publishing, Managed Care Information Center, 1913 Atlantic Ave., Suite 200, Manasquan, NJ 08736; (732) 292-1100,

  This article was taken from:
Healthcare Reimbursement Monitor

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