Editing Health Insurance Claims: What does it mean to delete an insurance claim?

During the rigorous training that doctors undergo to learn their trade, very little education is received on how to deal with filing claims with insurance companies. Unfortunately, it’s a necessary evil, as the doctors who contract with the insurance companies rely on that reimbursement as the lifeblood of the practice’s survival.

Getting paid from insurance payers involves filing claims after providing treatment. Whether in an office, emergency room, or operating room, filing a claim involves providing the appropriate procedure and diagnosis codes along with the appropriate modifiers related to the treatment performed. However, simply filing a claim does not guarantee that it will in fact be paid.

Insurance company policies for accepting or denying claims change frequently. A claim that was paid last month may currently be denied without notice, depending on carrier-specific modifications. This results in a large number of denied claims for doctors who perform many of the same procedures. Not only is it confusing for a practice to try to keep track of these adjustments, but it can result in long days in accounts receivable along with roller coaster collection periods.

Is there a secret weapon doctors can use to help simplify claims to maximize acceptance? That’s where the “scouring” claim comes into the picture. The term “purge” refers to a complex cleanup of a claim prior to filing. Over the past 10 years, automated claim editing has been developed to help validate that a claim is appropriate and accurate for submission.

There are two components to washing affirmations. Since the most common error for denied claims is data entry errors, patient demographics are reviewed for common errors. For example, entering incorrect procedure code that is age-specific would invalidate the claim, and the debugger flags those types of errors to fix before committing. This is the easy part of automation.

The tricky part of the cleanup involves a thorough review of codes and modifiers to ensure compliance with carrier-specific guidelines. This is commonly referred to

as the “rules engine”. Somehow, each claim data element is analyzed. If a doctor files a claim for a hysterectomy and the scrubber sees a male gender, it will obviously be flagged. The debugger verifies that a procedure performed is associated with a diagnosis code justifying the medical necessity of that procedure along with variables such as gender, age, date and place of service, and any required modifiers.

The complexity of washing should not be underestimated. When the total number of local and national Medicare coverage determinations is multiplied, along with data from the Correct Coding Initiative (CCI), ICD-9 codes, and the potential number of editable combinations is modified, it exceeds ten million. . However, advanced claim debuggers can review around ten claims per second.

By including national and local coverage determinations from all geographic Medicare regions in each state along with data from the Correct Coding Initiative (CCI), approximately 35% of existing CPT codes are represented for reference in code editing programs. claims. There are no Medicare medical necessity guidelines for the remaining 65% of codes, so claims scrubbing software companies hire full-time doctors and nurses evaluating up-to-the-minute medical necessity data published by the insurance companies from around the country on their website as required by law. . Additionally, procedure codes are compared to all feasible diagnosis codes believed to be clinically defensible for claim acceptance. Unsurprisingly, this is an expensive endeavor, which is why most claim that debugging software companies license this part of the few companies that do the research.

So how good are the existing claim debuggers? There is a wide range available, either as a stand-alone product or integrated with practice management software. Often the billing company used will have a built-in debugger. The best ones will routinely achieve over 95% claims acceptance on the first pass. Practices that previously performed manual edits typically find that after instituting the technology, the debugger catches more than 30% of complaints. This means around 30% potential claim rejection before cleanup, which lengthens the revenue cycle. By having the debugger flag problem claims, changes can be made instantly before committing, instead of waiting weeks for a denial. As a result, the practice will see more refunds and receive those funds faster. There will also be less administrative work secondary to denied claims.

Can trusting an experienced coder achieve the same acceptance rate? In all probability, no. As mentioned, debuggers check demographic information along with the codes. Also, if a payer changes a filing guideline on their claim form or a medical necessity requirement, a certified coder may not know in a timely manner. If a doctor contracts with a large number of companies, the chances of being the subject of rejected claims increases dramatically without a way to continually monitor these myriad and often complex requirements.

Adopting an advanced claims scrubber, either directly or indirectly, will enable one’s practice to effectively combat the intricate world of insurance claims rules and regulations. Practices that incorporate grievance screening rarely stray from the process. When the bottom line gets a significant boost along with the peace of mind that comes from knowing the latest technology is in your back pocket, why would they?