Key Insurance Claim Challenges Facing Medical Practitioners

The challenges of running a successful healthcare practice are much greater than providing high-quality patient care. In order to run a successful dental clinic, laboratory, hospital, or solo practice, there are several things you have to get right, including insurance billing.

The challenges of running a successful healthcare practice are much greater than providing high-quality patient care. In order to run a successful dental clinic, laboratory, hospital, or solo practice, there are several things you have to get right, including insurance billing. The healthcare revenue cycle depends on receiving accurate insurance reimbursements.

When it comes to insurance claims, medical practices face the following challenges:

Missing and Incorrect Patient Information

Claims are often rejected due to missing or incorrect patient information. Patients' demographics and insurance information are usually not cross-checked by the front desk team. Inaccurate data submission could lead to claim rejection. By using a patient portal, it is possible to verify the accuracy of patient demographics and insurance information. Patients can be immediately informed if inaccurate information is provided by the front desk team. When patients and insurance information are accurate, clean claims are submitted, resulting in faster insurance payments.

Improper Coding

Medical coding is often handled by small healthcare practices or solo practitioners. For all patient visits, they tend to use three to four procedure codes (CPT). Healthcare providers are trained in medical coding, a specialized branch of medicine. Up-coding and other forms of medical abuse and fraud can have more serious consequences, including fines and penalties from the federal government. Coding for medical specialties requires experience and specialized knowledge. Moreover, such coders are hard to find and incur high costs on the payroll.

Non-Covered Services

Most physicians, hospitals, prescription drugs, wellness care, and medical devices are covered by insurance companies. Certain items and services are not covered by Medicare or other commercial insurance companies. Often, patients are unaware that their insurance no longer covers the service they need until it is time to pay. By verifying patients' insurance coverage at every visit, it is possible to overcome this challenge. In case of inactive or non-covered insurance services, check if the patient has additional coverage. Providers should inform patients that they may be responsible for the payment if their insurance doesn't cover planned services.

Missing Referral or Authorization

Some healthcare services require referrals from primary care physicians before patients can access them. 

When a patient requests a specific doctor, such as a specialist, the physician may write a prescription referencing that doctor. Some insurance companies require referrals to be more formal than scripts.  Before a procedure can be performed, an authorization request is made to the insurance company, also known as pre-approval or pre-certification. Certain procedures require authorization from insurance companies. Claim denial can occur if patient services do not provide such referrals or authorizations. Before submitting claims, the provider's office must understand these requirements and work with patients to obtain the necessary referrals or authorizations.

Missing Documentation

In order to pay certain claims, insurance companies require documentation. An effective continuum of care requires accurate and complete documentation in the medical record. Prior to approving surgery, insurers want to know if the patient has tried cheaper alternatives. If the documentation does not support a definitive diagnosis or does not support severity, the insurance company may deny the claim. In addition to telling the patient's story, accurate and complete documentation can even improve the patient's care. To improve documentation, most experts suggest establishing provider education at the classroom level. Provider needs to document clinical decision-making, rather than just documenting everything.

Claim Rejections and Denials

In a study conducted by the California Nurse Association, 22 percent of the claims were rejected. The percentage of denied claims varies by practice, ranging from 10 percent to 60 percent in some cases. According to this survey research, 40 percent of denials are never appealed, and 65 percent are never resubmitted. For any practice to remain financially viable, insurance reimbursements must be accurate. When claims are denied or rejected, your practice can suffer severe losses. Managing this insurance claim challenge requires providers to work with experienced billers and coders to understand denial reasons/patterns, resolve them, and appeal them in a timely manner.

Lack of Patient Education

Medical billing is generally unknown to patients. Some people may not realize that their insurance coverage has changed, or that they need a referral or authorization to access the services. Educating patients about financial responsibility is the obvious solution. It is common for patients to be reluctant to pay co-payments, deductibles, and co-insurance after paying their insurance premiums. Patient contributions are increasing exponentially and more patients are accepting High Deductible Health Plans (HDHPs), so it is always best to educate patients about treatment plans, insurance coverage, and patient payment options. The more educated the patient, the more likely they are to complete treatment and to make the payment at the time of the visit.