No doubt, claim denials have become a common phenomenon in healthcare practices. But a high percentage of rejected claims can lead to a financial crisis i.e revenue leakage, cash flow disruption etc.
Denied /rejected claims not only result in delayed/partial payments. But also increase the financial as well as the administrative burden of healthcare providers. As the cost to rework the claim is approximately $118 per claim. Moreover, the resubmission of medical claims takes more efforts and time than submitting the claims the first time.
However, medical practitioners can significantly reduce the number of claim denials by implementing a prevention-focused denials management strategy.
When it comes to crossover medical claims, the rate of denied claim witnesses a surge from the past few years. Because it’s a little bit complicated to handle the crossover claims.
What is a Crossover Claim?
A crossover claim occurs when a patient is eligible for both Medicare and Medicaid healthcare plans. In this case, Medicare pays a portion of the claim, meanwhile, Medicaid is billed for any remaining deductible and/or coinsurance.
Before further discussion, let it be clear that Medicare is a federal program that is designed for the:
- People who are 65 or older.
- Certain younger people with disabilities.
- Patients suffering from kidney failure and require dialysis or a transplant.
On the other hand, Medicaid is a combined federal-state program that covers low-income people regardless of age. Because of overlaps in eligibility criteria, some people may be covered by both programs.
How to Handle the Crossover Claims?
Federal centres for Medicare and Medicaid has set the following rules to submit such claims:
- You don’t need to file the claims directly to Medicaid for those patients who are eligible for both programs. For complete reimbursements, medical practitioners have to submit all crossover claims to Medicare.
- After submission, Medicare assesses the claim, pays its portion of the bill, and then submits the remaining claim to Medicaid.
- The portion that Medicaid will pay all depends on the state rules, where you have submitted the claims.
- Once Medicaid has handled its portion of the bill, the claim is closed.
Ways to Prevent the Claim Denials?
Before implementing smart solutions to prevent claim denials. It is crucial to get a better idea of the major reasons behind claims denials.
Here are the most common reasons and tips to prevent claim denials/rejections.
1. Accurate Medical Codes:
The incorrect transformation of a particular injury, treatments and medical services into universal medical codes is the major reason behind claim denials. As a result, healthcare providers lose a significant amount of revenue.
Therefore, you should acquire the assistance of certified medical coders. Because they can save your practice from financial as well as legal challenges by preventing upcoding, under coding, etc.
If healthcare providers can’t maintain accuracy in the entire coding and billing process. Then they should outsource their medical billing coding services to a trusted third party. Outsourced medical coders have in-depth knowledge about the ICD-10 and the latest changes in the medical codes. That enables them to process the claims with an accurate set of codes.
2. Avoid Claims Duplication:
Duplicate billing occurs when you submit a medical claim to payers for the same patient procedure, treatment, or testing on more than one occasion. So, in order to avoid claim denials, make sure that there is no duplication of claims.
3. Meet the Filing Deadline
Regardless of how complete and right the code and data, if the claim is submitted after the deadline. Then it gets denied. Therefore, you must submit the claim forms within a required time frame.
Deadlines to submit Medicaid claims vary by state, and your state’s Medicaid program may not pay late claims. So make sure that medical billers submit the claims in a given time frame.
4. Fill the Claim Form Carefully
Medicare and Medicaid require complete/accurate information to process your claim form. If you don’t enter all the information a form requests, then your claims will be rejected. And you will have to resubmit it.
In addition to this, make sure that your billing team is processing the claims with up-to-date and accurate information. Because the base of claim denials can come directly from the beginning while collecting information at the front desk.
Because erroneous DOB, wrong insurance ID, and missing data are some other normal mistakes that lead to claim denial. It occurs when your staff doesn’t properly check fundamental information about patients. They end up sending mistakenly filled up claim forms which obviously lead to the claim denials/rejections.
Therefore, you should keep a close eye on your registration staff. And make sure that they collect accurate patients’ demographic information such as: name, gender, date of birth, address, insurance policy etc.
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Related Tag: What Are The Reasons Of Claim Denials?