[This post was originally published on 9th June 2021. It has been updated on 28th May 2024.]

Have you ever analyzed the number of claims that got approved by the insurance payers after the first submission? According to the Change Healthcare 2020 Revenue Cycle Denials Index, 11.1% of claims were denied upon initial submission through the third quarter of 2020 in the U.S. Whenever a claim is being denied by a payor, a practice needs to find the reasons for the denial, take appropriate actions to correct the information on the claim, and then resubmit it again. This takes an enormous amount of time and effort to correct and resubmit a claim.

If a chiropractic practice is able to increase the number of ‘clean’ claims, it can easily reduce avoidable claim denials and save time and efforts spent on claim resubmission. But claim denials are preventable only if you know how to submit a clean claim on the first try. If you are using chiropractic billing software at your practice, then you know how much electronic claims submission can improve your reimbursement cycle. But even with billing software for chiropractic practices, there are certain things that billing staff at practice should take care of before and during the claim submission process in medical billing to get it right the first.

If you’re interested in finding out more about how managed billing specialists can streamline the claims coding and submission process and help you increase your revenue while saving you time, efforts, and money, contact zHealth’s Billing Experts now.

Top 10 reasons for claim denials according to the Change Healthcare 2020 Revenue Cycle Denials Index: 

• Registration / Eligibility Missing
• Invalid Claim Data
• Authorization / Pre-Certification
• Service Not Covered
• Medical Documentation Requested
• Medical Necessity
• Untimely Filing
• Medical Coding
• Provider Eligibility
• Avoidable Care

5 steps To Ensure Clean Claims Submissions at Your Practice

Step 1 – Verify Coverage Eligibility

A patient might have primary insurance, secondary insurance, sometimes tertiary insurance. But that does not mean these insurances cover chiropractic care or services. It can be possible the patient’s insurance covers only a number of visits or certain types of visits.

Before you proceed with the claim submission process in medical billing, the first thing you need to do is to verify the insurance eligibility of the new patient. Keep checking the eligibility of existing patients’ insurance plans once a year. This is because you won’t get paid for your claims if a patient’s coverage has lapsed or the patient has changed his or her insurance plan.
A practice should also verify insurance plan effective dates, covered and non-covered services, in-network or out-of-network benefits, copays and deductibles.

Step 2 – Complete Pre-Authorization Process (when required)

Most insurance companies cover medically necessary, appropriately authorized chiropractic services. If you don’t complete the pre-authorization process for insurances that require prior authorization (pre-certification) for chiropractic services, your claims will be denied by those payers.

However, there are some exceptions in chiropractic pre-authorizations.

For instance, Blue Cross Blue Shield Massachusetts requires chiropractors to request authorization for patient visits beyond 12 per calendar year.

There are exceptions in payment options for in-network vs out-of-network providers with regards to the pre-authorization process. For instance, an in-network provider who failed to comply with the pre-auth process is denied the insurance claim and gets a provider write-off. On the other hand, an out-of-network provider who failed to follow the pre-auth process is also denied the claim, but the provider can request the patient to pay for those denied services.

Step 3 – Correct Patient & Provider Information on Claims

CFA Form, also known as CMS 1500 Form, has as many as 33 blocks. When submitting a claim to an insurance company, a practice needs to conform to the policies of the payers and meet the guidelines of the Centers for Medicare & Medicaid Services (CMS).

Every claim file contains details specific to the patient, patient encounter, and provider. We will discuss the details related to the patient encounter in our next step. Let’s talk about patient and provider details.

It is essential to add updated and accurate patient information on claims. Basic data entry mistakes while adding a new patient to the EHR and billing software can prolong the reimbursement cycle. While these details are quick to fix when resubmitting a claim, but why waste time and money when it is actually beneficial to get it right the first time.

Make sure the following patient information is correct during claim submission in medical billing:

Patient full name, date of birth, gender, address, zip code, name of the patient’s insurance company, insured’s name and policy number,insured’s group policy or FECA number, member ID, and secondary or tertiary insurances (if available and cover your chiropractic services).

Make sure the following provider information is correct when you submit claims:

• Billing provider name, address, zip code, and telephone
• The service facility name, address, and zip code
• Provider tax ID number and type
• Provider NPI number
• Referring provider name and NPI (if any)

Step 4 – Patient’s Encounter – ICD-10 and CPT Codes

Incorrect diagnosis and procedure codes can result in claim denials. A practice can make an appeal and submit the claim again with correct codes, but prevention is better. Every code related to patient visits has to be accurate and in proper order for a smooth reimbursement upon claim submission. A few of the errors related to chiropractic billing and coding that can cost thousands of dollars in lost revenue:

4.1. Not using updated code sets – The organizations that regulate and update the ICD-10 and CPT codes are the National Center for Health Statistics (NCHS) of the CDC and the American Medical Association(AMA) respectively. They update these manuals yearly so it is important to know the changes and apply the new or revised codes correctly when billing an insurance company.

4.2. Upcoding and undercoding – When someone bills for an expensive or complicated process than what was performed, it is called upcoding. Undercoding refers to the process of using more affordable service codes than what was performed.

4.3. Not linking diagnosis codes to the procedure codes – Coding errors occur when a provider forgets/fails to link a diagnosis code to the CPT code.

4.4. Lack of medical necessity – A payer won’t pay you if it deems a procedure to be medically unnecessary. It is essential for the billing staff, clinical staff, and the provider to communicate to better understand procedures performed, services rendered, patient history, and insurance contract policies.

4.5. Unbundling – When a provider or biller uses separate codes for linked procedures instead of using a single code for grouped procedures, it is termed as unbundling.

4.6. Incorrect modifier usage – Incorrect usage of modifiers with the CPT codes can be costly. Modifier confusion can cause your claims to be denied by the payer(s) or even result in fraud accusations.

It can be difficult to keep the billing and coding errors in check if a practice follows a paper billing process or the in-house staff is too busy to meticulously check all boxes in the HCFA form before the medical claim submission process. This is where chiropractic billing software comes out to be a powerful tool.

Billing software for chiropractic practices makes your billing process efficient and error-free. Billing software comes integrated with a clearinghouse that offers claim scrubbing services with the capabilities to find claim errors before the claims go to the payers. You get a report of these errors in your software. Make corrections to the claims and submit them again so that the clearinghouse can forward it to the payer.

Step 5 – Timely File Your Claims

Timely filing of claims is important during the claim submission in medical billing. Insurance companies provide a timeframe to providers within which a claim must be submitted to them. The timeframe varies from one payer to another. Some insurances provide 90 days to providers to file a claim, while others allow claim filing no later than 12 months from the date of service. When a practice fails to send out a claim within a payer’s timely filing standards, the claim will be denied by the payer. The practice won’t be able to bill a patient or appeal to the payer if they missed the deadline for claim submission. Make sure your practice files the claims in a timely fashion to avoid denials or write-offs.

Billing Management Tips

One thing that can help build an accurate “medical billing claims process” and ensure an optimum percentage of clean claims.

Chiropractor billing software comes integrated with an EHR solution that enables your practice to maintain detailed patient documentation, such as patient history, SOAP notes, procedure documentation, and services performed. If required by payers, you can easily email the patient’s documents as supplemental records for claims processing or for audit purposes.

Billing software performs quality checks prior to electronic claims coding and submission. It comes integrated with a clearinghouse that performs claim scrubbing to find formatting errors, missing details, and inaccurate coding combinations.

You will never miss a payer’s filing deadline with 3-click claim submission process in the chiropractic billing process. You can submit a claim as soon as you create an invoice.

Billing software is updated with new and revised diagnosis and procedure codes. No need to memorize codes or maintain a separate sheet with code details. Billing software auto-populates codes when you type a few letters or numbers of the code you’re looking for. You can create your code favorite lists to save time and increase efficiency when creating an invoice.

Conclusion

Improve the pre-claim process and simplify the claim submission process by implementing automated billing and claim submission software. The billing software will not only help you increase billing efficiency and profitability, but you will also see an improved rate of paid claims upon the initial submission. If you’re interested in finding out more about how zHealth can help you grow your practice revenue, decrease denials, and increase number of clean claims rate, contact zHealth at+1 (800) 939-0319 or request a free demo here.

Frequently Asked Questions

 

Q1: Why is it important to review claims prior to submission?

A1: If you are using chiropractic billing software, then you know how much electronic claims submission, posting and processing can improve the speed of your reimbursement cycle. But even with the advantages of technology, there’s always room for improvement.

Let’s look at some of the tips you can implement during the pre-claims process to speed up the cycle of getting paid and increase efficiency.

• Verify Insurance Eligibility

Need a chiropractic office manager or staff member who will verify insurance eligibility.

The most important first action item in your claim revenue cycle is to double check eligibility prior to every new patient appointment.

• Don’t Skip Pre-Authorization

If applicable, complete the pre-authorization process. If there are pre-authorization requirements in place, your claims may be denied – even if a patient has the chiropractic benefits on their plan. Unfortunately, if you are contracted, then pre-authorization denials mean you’re not getting paid.

• Make Sure Data Is Accurate

It is crucial to ensure you have up to date and accurate information on patient’s insurance, contact details, SSN number, and other details.

• Partner with Billing Experts

Speaking of inaccurate coding combinations, staying current with codes and identify billing trends is virtually impossible for chiropractic office managers and staff. The billing process is complicated, stressful, and can change on a dime. Partnering with chiropractic billing experts who do all the hard work for you is well worth the investment.

Q2: Why is it important to review claims prior to submission?

A2: There are many factors that increases the number of claim denials in the chiropractic industry. Whether the provider or payer is at fault, it is understandable that denials occur because of how complex the chiropractic coding and billing system is. Providers must work closely with their in-house or outsourced medical coding professionals to ensure patient information is documented accurately and claims are submitted on time. Below are six of the common reasons for denials in the medical billing claims process:

1. Claims are not filed on time
2. Inaccurate insurance ID number on the claim
3. Non-covered services
4. Services are reported separately
5. Improper modifier use

Q3: Why are claims rejected?

A3: Denied or delayed chiropractic claims can adversely affect the financial health of your practice by reducing cash flow. Studies have revealed that year on year; chiropractors lose as much as 30% of their potential and earned revenue due to claim denials and reimbursement delays. Chiropractors who understand how to properly combat insurance denials will fair better than their peers and remain financially solvent. Your billing staff should make every effort to avoid these common mistakes and follow-up on all denials and rejections.

1. Claim is missing information
2. Claim contains incorrect patient identifier information
3. Requires prior authorization or pre-certification
4. Lack of coverage in patient’s insurance plan

To avoid claim denials, it is essential to work with professionals who can manage your billing and claim submission services. 

Q4: What are the possible solutions to a denied claim?

A4: Researching and re-submitting denied claims is a time-consuming and frustrating process. It’s critical to have a claim denial management strategy in place to quickly identify, resolve, recover, and prevent denied claims. Knowing some basic strategies for resolving claims denials can save practitioners time and improve their practice’s cash flow.

1. Carefully review all notifications regarding the claim
2. Be persistent
3. Don’t delay
4. Get to know the appeals process

Denied or delayed chiropractic claims can adversely affect the financial health of your practice by reducing cash flow. Studies have revealed that year on year; chiropractors lose as much as 30% of their potential and earned revenue due to claim denials and reimbursement delays. Chiropractors who understand how to properly combat insurance denials will fair better than their peers and remain financially solvent. Your billing staff should make every effort to avoid these common mistakes and follow-up on all denials and rejections.

1. Claim has missing information
2. Claim contains incorrect patient identifier information
3. Requires prior authorization or pre-certification
4. Lack of coverage in patient’s insurance plan