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So many issues contribute to the soaring volume of claim denials. And those claims denials affect medical organization revenue opportunities adversely. While it is common knowledge among those of us in the industry that medical insurance billing complexity is increasing exponentially, not so common is the knowledge of root cause and how to proactively correct and improve denial patterns.

Where does the denial begin? Perhaps issues are technical - incorrect data parameters in the system. Or perhaps the technical issues simply compound the human equation - rapidly changing regulations are difficult to keep up with, sheer transaction volume can overwhelm staff billing staff who already spend non value added time on researching duplicate claims or touching a claim multiple times as part of re-work. The bottom line is immediately impacted with increased labor costs combined with decreased cash flow.

The Center for Medicare and Medicaid Services (CMS) notes that one common reason for claim denials is not meeting Medical Necessity requirements. Another respected source, Noridian Medicare Bulletin, provides a "Top Ten" for responsible claim denial errors. Unlike Letterman's "Top Ten" this list is far from laughable.

1. Records indicate the performing physician, supplier or practitioner is a member of a group practice; however, the individual and group NPI/PINs were not entered accurately.
2. Patient cannot be identified as our insured.
3. Payment denied due to procedure code/modifier was invalid on the date of service or claim submission.
4. NPI/UPIN of the ordering, referring or performing physician is missing or invalid.
5. Procedure code is inconsistent with the modifier used, or a required modifier is missing.
6. Did not complete or enter accurately the CLIA number.
7. The procedure code/bill type is inconsistent with the place of service.
8. Referring, ordering, supervising provider's name and/or UPIN/NPI are missing or incomplete.
9. Item 11 not completed.
10. Missing, incomplete or invalid information on where the services were furnished.

So where's the gold? The revenue that medical organizations need to survive? A map is usually pretty helpful when looking for buried treasure. Healthcare billing just needs that map, the one that can find hidden revenue opportunities. Identify the root of the problem when you examine the overall revenue cycle. Based on the most common errors, we put together a matrix to help identify affected processes, probable root causes, and possible resolution activities. The matrix on page 2, developed by Derry, Nolan & Associates, LLC, helps identify the processes that are affected, probable root causes, and some action items for resolving the issues.

Set your organization up to win. Train, test and audit staff and providers routinely so any deficiencies leading to denials are identified and resolved quickly. Render the "gold" tangible with revenue your organization deserves because it proactively addresses workflow problems, infrastructure issues and training gaps.

Ms. Antonio can be reached via email > here.