Rejected Claims

At the heart of every rejected claim lies some sort of error – a slip of the finger, an incorrect code, and missing information are all things that can lead to rejection. And rejection means a delay in payment, so it’s of utmost importance to get it right the first time. RCM360® can help set up processes to help you do just that, and we’ll also help you clean up an old stockpile of rejected claims you may have lingering in your practice.

There are several possible causes for rejected claims, and a variety of strategies RCM360® will employ to remedy the situation.

Cause #1: High Denial Rate
  1. The RCM360® team will perform a thorough assessment of the denials, identifying the top, most commonly denied codes in your practice and determining why they’re being denied. It could be a case of incorrect documentation, or an incorrect code that’s being entered into the system.
  2. RCM360® will call each payer on rejected claims to ensure the rejection is legitimate and proper and determine what must be done in order to get it paid.
  3. A plan will then be created to rectify the situation. This entails:
    • Clear definition of codes
    • Creation of processes by a certified coder
    • Internal training on proper coding
    • Ongoing monitoring of rejected claims
    • Quick remedy for rejected claims moving forward with rejections addressed within two business days
Cause #2: Lack of Timely Submission of Claims
  1. RCM360® will analyze claims that were rejected because they weren’t submitted according to the payer’s eligibility timeline. In other words, they were submitted too late.
  2. Our team will review the lag times to determine where process issues or training needs may exist.
  3. We’ll develop a plan to streamline the process to help ensure on-time submission, as well as to streamline claim correction and resubmission.
  4. Ongoing monitoring will be established, and review processes will be implemented to identify and rectify workflow issues more quickly.
Cause #3: Patient Ineligibility
  1. RCM360® will review and indentify any rejections that resulted from patients not being eligible for the service, or not being pre-certified for the service by the insurance company.
  2. In many cases, these are oversights and can be rectified with the implementation of workflow processes.
  3. Our team will implement automated eligibility checking and identify process changes to help avoid this type of rejection.
  4. We’ll then monitor this regularly to identify and resolve the issues as quickly as possible.
Cause #4: Missing Referrals
  1. In specialty practices, referrals from a primary care physician, as well as pre-authorization for the service, are typically required for a claim to be paid.
  2. RCM360® will complete a thorough review of this type of denial, identifying the cases and determining a course of action for each.
  3. Claim engine rules processes will be implemented to quickly flag missing referrals based on payers with high denial rates.
  4. Ongoing monitoring will be put in place, with regular reporting to address these situations as they arise rather than months later when it may be too late.