Oncology Practice Management and the Practice Management Institute are proud to present our exclusive series on optimizing the patient experience. In this month’s edition, we present strategies to navigate reduced reimbursements, delayed reimbursements, and denied claims. This article was reviewed by Jan Hailey, MHL, CMC, CMCO, CMIS, CMOM, CMCA-E/M.
Billing managers in oncology practices face a complex landscape when dealing with insurance claims. Challenges such as reduced reimbursements, denied claims, or reimbursement delays can significantly impact the practice’s financial health and patient care continuity. Here are 5 effective strategies for managing these challenges drawn from guidelines issued by healthcare finance and insurance experts.
1. Conduct a Thorough Review of Disputed Claims
Billing managers are advised to conduct a thorough review of all denied or reduced claims. Verify that documentation is complete and accurately reflects the services provided. This step is crucial for identifying any errors, discrepancies, or missing information that could provide the basis for an appeal.
2. Understand Insurance Policies
Understanding the specific policies and requirements of different insurance carriers is essential. Update and confirm the patient’s eligibility and policy status, follow required billing and coding procedures, and review applicable laws and regulations. Being well versed in the nuances of insurance contracts can help prevent denials due to policy misunderstandings.
3. Know What Constitutes an Effective Appeal
An effective appeals process for denied claims may start with a phone call to clarify the reason for denial of the claim. Keep accurate records of calls. To submit a written appeal, gather all necessary documentation, compose a detailed appeal letter that references specific policy guidelines, and follow up diligently.
4. Be Proactive in Communicating With Insurance Carriers
Proactive communication with insurance carriers is key and may prevent billing issues from occurring in the first place. Establish a direct line of communication to help clarify reasons for denials or delays and expedite the resolution process. Present clear and concise information and maintain a professional manner.
5. Educate Patients and Advocate for Them Throughout the Process
Billing managers play a critical part in patient advocacy. When necessary, assist patients in understanding their insurance coverage and out-of-pocket responsibilities and guide them through the appeals process to help alleviate additional stress and improve their overall care experience.
Conclusion
Navigating the intricacies of insurance claims in oncology practices is complex. By implementing thorough documentation practices, understanding insurance policies, using an effective appeals process, maintaining proactive communication with carriers, and advocating for patients, billing managers can effectively address claims that are reduced, denied, or delayed, ensuring the financial stability of the practice and the uninterrupted care of patients.
About the Reviewer
Jan Hailey is a WPS Government Health Administrators (Medicare) Provider Outreach and Advisory Group member and has been instrumental in developing Practice Management Institute’s Workforce Initiatives program. She has a Master of Health Leadership degree and five professional certifications in office management, coding, insurance processing, auditing, and compliance.