Practice Management Alert

Add these checklists to your resource repertoire.

Are you ever shaking your head while looking over your claim denials, realizing that simple mistakes are costing your practice money and a lot of time?

“A lot of claim denials are due to the initial reporting,” says Terry A. Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMC, QMGC, QMCRC, QMPM, a Healthcare Coding & Billing Consultant based in Laguna Beach, California.

Understand What Constitutes a Clean Claim

Context: “A clean claim is one that has no defect, no impropriety, and no special circumstances. It doesn’t have incomplete documentation, if requested, and it doesn’t have anything that delays timely payment. A provider that submits a clean claim by providing the required data elements on the standard claims, along with any attachments or elements of revisions that they need, they have a much better chance of getting paid on the first try,” Fletcher explains.

Utilize This Checklist for Accuracy Within Your Office’s Records

1. Make sure that the policy number and ID number are accurate when put into the system. “Sometimes these numbers can be transposed or otherwise inaccurate,” Fletcher says.
2. Obtain insurance eligibility verification. Just because a patient presents your office with insurance information or you have their card on file doesn’t mean it’s current or accurate. Someone on your team should call to make sure that the insurance information is accurate, especially as more patients utilize the Affordable Care Act options for health insurance because those plans may be more likely to change more frequently than employer-tied plans.
3. Verify other patient information, like names. Make sure that people’s formal, official information is consistent across your records and their insurance. For example, if the patient’s name is Joseph but he goes by Joe, make sure “Joseph” is being used across your records.
4. Make sure birth dates are correct, especially the year. Although it’s common to include only the last two digits of a year, it’s safer to use all four. Write out 2022 instead of 22 when writing dates.
5. Check addresses, especially if the patient receives mail at a different address than where they live. Some patients may have post office boxes where they receive mail, instead of at their physical street addresses where they reside. Make sure they know — and, thus, you know — which address is connected with their insurance plan so you’re including the correct information where needed.
6. Confirm information for posting charge entries from provider. If your physician provides you with a face sheet from, say, a hospital, make sure the information is up to date and accurate before you rely on it.
7. Make sure your CPT® and ICD-10-CM codes are current and accurate for the information you are trying to convey. Make sure they’re as specific as possible. Don’t forget to include the insurance authorization information, if applicable, Fletcher notes.
8. Include the referring doctor’s national provider identifier (NPI).

Use This Checklist for Claims

1. Double-check for unnecessary spaces. Even if the patient’s ID card uses spaces, you cannot have a clean claim if you have spaces in the electronic claim form, Fletcher says.
2. No symbols in the patient ID. This includes dashes, asterisks, and special characters. It has to be exactly as it appears on the card — expect for spaces and symbols.
3. Don’t add a plan type from the card in the group number field. Group numbers are numerical only. (A plan type may be listed on a patient’s insurance card if they have insurance through their employer and there were multiple options from which to choose, say, A through F.) Using a letter in this numeral-only space will mean it’s no longer a clean claim.
4. Use the correct authorization number, which might include a certification number or a preauthorization number. “If that’s given to you by the carrier for either the surgery or procedure or diagnostic, make sure it’s the exact authorization number provided by the carrier with no extra characters,” Fletcher says.
5. Don’t add notes in the authorization box, which is box 19 or the extra comments box on the electronic claims form. Don’t add any comments like “no auth required,” Fletcher warns. “Always leave this blank if authorization is not required, otherwise this could cause your claim to be denied.”

If you’re seeing a lot of denials, call a meeting with your billers and distribute this checklist. Even if your billers are on top of their work and submitting clean claims, distribute this checklist so they have an extra set of standards to check their work against. If you have a shared drive (see story, page XX, for more information), these checklists may be a great addition to your resource library.

Top tip: To be especially certain that the patient is covered and your practice will get paid by the carrier, make sure you verify that the patient’s insurance is accurate for the date of service. Otherwise, your practice may find itself in a situation where a team member has called to verify coverage, your provider renders services, a team member files the claim, but you get a denial back saying that the patient was not covered on the date of service or the carrier pays your practice but wants the money back six months later for the same reason, warned Karlene Dittrich, CPC, CPMA, ERISA/PPACA, a claims handling compliance and appeal specialist, during AAPC’s HEALTHCON 2022.