June 13, 2023 by AMS Solutions 0 Comments

Medical billing, one of the most critical components of the healthcare industry, involves complex terminology that often has the ability to confuse even long-time professionals. One of these terms that we’ll be taking a look at is the ICN. If you’ve been wondering “What is ICN in medical billing?” or “What is an ICN number?” then stick around. We’re going to do a deep dive into this term, what it means, and why it’s so important to medical billing. 

ICN in Medical Billing: A Snapshot

Inside the world of medical billing, every single transaction,  no matter what it’s for, is tracked with unique identifiers, from the average patient visit to complex or intricate surgical procedures. The ICN, short for Invoice Control Number, is a unique identifier that functions similarly to a tracking number on a shipped parcel. It helps insurance companies monitor claims by giving them access to each individual claim.

Unraveling the ICN Number

So what is the unique significance of the ICN, and why should medical practices care about understanding the specifics behind them? The ICN serves as one of the key reference points throughout the entire claims process. It’s uniquely assigned to each claim that’s created, allowing insurance providers to track its status more effectively. 

When a healthcare provider submits a claim to the insurance company, no matter what the reason, the claim is tagged with an ICN. This unique number stays with the claim from initial submission through the final adjudication, which provides a clear and consistent point of reference for the insurer.

Why is ICN Crucial in Medical Billing?

Knowing “what is ICN in medical billing” is critical information for seamless operations. It helps aid in tracking the claim’s journey, investigating any discrepancies, and facilitating effective communication between various healthcare providers and insurance companies. ICNs are especially beneficial when a claim gets denied or requires reprocessing

The ICN number serves as the claim’s unique identifier, simplifying the process of locating the claim in question. Therefore, having a clear and thorough understanding of the answer to the question of “what is an ICN number” is a central component to efficiently navigating the complex landscape of medical billing.

AMS Solutions Has Leading Skills and Expertise in Medical Billing

At AMS Solutions, we have a unique and unmatched understanding of the nuances of medical billing. We know that comprehending terms such as ICN can be challenging, but it’s also integral to your practice’s financial health. That’s why we offer comprehensive medical billing and collections services, designed to help you navigate the system with ease.

We not only explain what ICN is in medical billing, but we also manage all aspects of your billing cycle. From claim submission to track, from denial management to reprocessing, we handle it all. We’ll take care of the complexities so you and your staff can focus more intently on what it is that you do best, which is providing leading care to your patients. 

Harness the Power of Effective Medical Billing with AMS Solutions

Understanding what is an ICN in medical billing is crucial for the effective and efficient management and tracking of claims. As a unique identifier, the ICN serves as a vital tool not only for communication but also for the resolution of discrepancies between healthcare providers as well as insurance companies. 
At AMS Solutions, we’re fiercely passionate about helping your organization to succeed by helping to simplify and streamline the complex tasks associated with medical billing and coding. We’re ready to handle all of your coding, billing, and collections needs so that your time can be better spent improving the health and lives of your patients. Reach out today for more information or to get started.

June 9, 2023 by AMS Solutions 0 Comments

Navigating the complexities of medical billing can be a daunting task for any healthcare provider, and chief among these complexities is gaining a clear understanding of the answer to the question “What is entity code in medical billing?” With the right information and guidance, it’s easier than you might think to master this critical aspect of the medical coding and billing process. AMS Solutions is ready to help, and our expert team can help you simplify and streamline your organization’s overall medical billing accuracy and effectiveness. 

What is Entity Code in Medical Billing?

An entity code, simply put, is a unique identifier assigned to a particular entity involved in a healthcare transaction. This can include healthcare providers, patients, insurance companies, or any other organization involved in the transaction. Having clarity about the role of the entity code in medical billing is vital to ensure accurate and efficient billing processes.

In the world of medical billing, entity codes are critical in streamlining the transaction process. They ensure that every billable service rendered, and every entity involved, is accurately represented, recorded, and processed. Moreover, having the right entity code in place can prevent delays or denials of insurance claims, thereby improving the revenue cycle of your healthcare practice.

Why is Entity Code Important in Medical Billing?

The core significance of the entity code in medical billing cannot be overstated. Accurate coding ensures a smooth and efficient billing process and eliminates possible confusion or miscommunication. This is crucial because a single error in the entity code can lead to dramatic consequences, including incorrect billings, delayed payments, and even denials for claims. 

AMS Solutions recognizes the critical importance of setting your coding and billing right, the first time, every time. With our comprehensive medical billing and collections service offerings, you can rest assured that each and every entity code is correct, that every claim will be processed promptly, and that every dollar owed to you is collected as efficiently as possible.

Choosing AMS Solutions for Your Medical Billing Needs

When you consider what entity code is in medical billing, the complexity can be intimidating or even overwhelming. However, with AMS Solutions, we can help take the burden off of your shoulders. Our expert team of healthcare billing professionals is incredibly skilled at managing the intricacies of entity codes in medical billing, making sure that your billing process is smooth, efficient, and as error-free as possible.

Our services extend well beyond simply helping to manage entity codes. With AMS Solutions, you get a partner who understands every single aspect of medical billing. Our team’s experience, expertise, and commitment to your success, ensure that your revenue cycle is optimized for maximum profitability.

AMS Solutions Is Ready To Be Your Trusted Medical Billing Partner

Understanding what entity code is in medical billing and its importance is key to a successful medical billing process. But you don’t have to navigate these complex waters alone. With AMS Solutions, you get more than just a service provider; you get a partner dedicated to your success. Our proficiency in managing entity codes and all aspects of medical billing and collections ensures that you can focus on what you do best, bringing leading care to patients.

Don’t let the complexities of medical billing slow you down. Choose AMS Solutions for all your medical billing and collections needs. Contact us today to learn more about how we can support your practice. Remember, with AMS Solutions, you’re not just optimizing your revenue cycle; you’re building the future of your healthcare practice. Make the right choice for your practice. Contact AMS Solutions today for more information or to get started.

June 6, 2023 by AMS Solutions 0 Comments

Medical assistants form a critical cornerstone of the healthcare sector, providing many essential support tasks to physicians as well as medical staff. As the healthcare industry continues to evolve every day, the role of the medical assistant is becoming increasingly crucial. That’s why credentialing for medical assistants isn’t just a trend, but an absolute necessity. We’re going to take a closer look at exactly why credentialing is important for medical assistants, and what it can do for their current and future employability.

The Impact of Credentialing

Credentialing for medical assistants is incredibly important. Credentialing serves as a professional endorsement and a sign of skill and competence. It’s a thorough process that validates and verifies a medical assistant’s skills, qualifications, and abilities. It is designed to ensure that they meet the essential standards that are required throughout the healthcare field. Credentialing isn’t just about checking off some boxes, it’s a robust assessment of a medical assistant’s general competency that helps ensure patient safety as well as the level of care quality they receive. Let’s dig into some of the biggest reasons that credentialing is important for medical assistants.

Credibility and Recognition

Having a professional credential gives medical assistants a crucial professional and competitive edge. It signals to their employers, colleagues, and patients that they have the necessary skills and knowledge to perform their job safely and effectively. It shows that they’ve gone beyond the basic training required and developed themselves personally and professionally, making them far more credible and recognized assets in the healthcare field. 

Career Advancement

Credentialing is also a career-boosting tool that can open a wide range of opportunities for medical assistants. With a rapidly changing healthcare industry, employers are recognizing the importance of certified professionals in their ranks much more frequently. This emphasis on certified professionals isn’t arbitrary either, instead, it’s a response to a dynamic healthcare landscape that simply demands more competent individuals. Credentialing sets medical assistants apart in the job market as well, by highlighting skills, commitment, and preparedness for any role they may take on.

Improved Patient Care

At its core, healthcare is all about patient care. The primary goal is to provide the best possible service and care to patients, and this is typically only achieved with qualified, competent healthcare professionals. This is where credentialing can set medical assistants apart. By ensuring that medical assistants are credentialed, providers are taking a significant step to ensure a higher level of overall patient care. Credentialed professionals have been tested and evaluated for proficiency, and are less likely to make errors during patient care. It also serves to demonstrate that an individual is invested in continuous learning and keeping updated in their field. 

AMS Solutions and Medical Credentialing

At AMS Solutions, we understand clearly why credentialing is important for not just medical assistants but all healthcare professionals. We specialize in comprehensive medical billing and collections services, including credentialing assistance. Our team will work diligently to simplify and streamline the credentialing process, ensuring that your medical staff is equipped with the necessary credentials to lead their field. This not only improves your overall healthcare delivery but also enhances your professional reputation within the healthcare industry as a whole. 

Partner With AMS Solutions To Streamline Credentialing

So, why is credentialing important for medical assistants? It gives them a credibility boost, opens doors for career advancement, and enhances patient care. The importance of credentialing simply can’t be overstated. When it comes to obtaining medical credentialing, partnering with an expert team like AMS Solutions can make all the difference. If you’re ready to elevate your healthcare career or delivery with credentialing, reach out to AMS Solutions today to get started.

Healthcare costs and fees concept.Hand of smart doctor used a ca
May 24, 2023 by AMS Solutions 0 Comments

The world of healthcare is complex and far-reaching, and managing the financial end of any practice can be a challenge. One of the most common questions that healthcare providers often ask is: “How much do medical billing companies charge?” At AMS Solutions, we believe in peak transparency, so we’re here to talk about that very subject. We’re going to take an in-depth look at the costs involved with partnering with a medical billing company. 

The Cost Variation

The first thing that is critical to understand is that not all companies charge the same rates, or even similar rates in many cases. Not only that, but some don’t even have the same pricing structure, so one company might charge or bill you in a completely different way for their time or services than another. Other factors should be considered when looking at the variance between what one company charges and what other charges. 

Percentage-Based Charges

One of the most common pricing structures for medical billing companies is the percentage-based structure. This means that when they need to figure out how much to charge for billing services, they simply look at the gross revenue for the practice, and charge a percentage of that. In most cases, percentage-based medical billing services will charge between 3% and 7% of the practice’s gross revenue. 

This model makes it easy for the billing company to align its interests with those of your practice. But it also leads back to the question: how much do medical billing companies charge in real terms? For example, let’s say your practice generates roughly $720,000 each month in revenue, and your medical billing service charges 5% of the gross revenue. You’ll be paying about $36,000 in billing service costs each month.

Flat-Fee Model

While less common, many medical billing services operate on the flat-fee model. AMS Solutions offers some flat-fee service plans, which can offer a far more predictable, fixed monthly cost for your practice. This is often a far more cost-effective solution, particularly with small and mid-sized practices, since it doesn’t fluctuate with the monthly revenue levels. This gives more stability and consistency to practices that need them the most. 

How Much to Charge for Billing Services?

Another question that frequently pops up is how billing service providers determine how much to charge for billing services. The answer to this can vary quite a bit, depending on factors like the total number of patients in a billing cycle, the complexity of the billing process, and the level of administrative support that’s needed to complement the billing. In most cases, billing service providers will charge anywhere between $1 and $10 per claim handled, with most averaging right in the middle of that range. 

Why Choose AMS Solutions?

With the constantly shifting healthcare landscape, and the often changing demands of small to midsize healthcare provider practices, choosing AMS can be one of the smartest moves you can make for your organization. We provide comprehensive coding and billing expertise which means you can focus on what matters for your practice, providing top-tier attention and care for your patients. Our competitive pricing and exceptional service and client satisfaction level mean you’ll always be getting the best value for your billing with AMS.

Trust AMS With Cost-Effective Management of Your Medical Billing Needs

Understanding how much medical billing companies charge can be a relatively complex process. However, with the right information and a trusted billing partner like AMS Solutions, it doesn’t need to be overwhelming. Reach out to AMS Solutions today for more information, or to get started discussing your organization’s needs.

May 19, 2023 by AMS Solutions 0 Comments

Do you run a healthcare provider practice and find yourself wondering, “What do medical billing companies do?” The good news is, you are not alone. With the continual expansion and growing complexity of the healthcare industry, the need for specialized services like medical billing and coding has risen dramatically over the past few years. 

But, what exactly do these companies do, and how do they function in our modern healthcare system? Let’s take a look at those questions, as well as why you should consider outsourcing your billing needs to one and what kind of benefits it may be able to offer.

The Basic Role of a Medical Billing Company

In the most basic sense, a medical billing company acts as a middleman between healthcare providers, their patients, and the insurance companies. They ensure that medical procedures that are performed are coded correctly in the records, the claims are submitted accurately and on time, and that the payments are collected promptly. 

This process might seem simple and relatively straightforward, but in reality, there is a substantial amount of attention that is paid to the detail and the understanding of the assorted medical and insurance protocols.

What Does a Medical Billing Company Do On A Daily Basis?

While this may not reflect the typical day at all medical billing companies, it will give you a general overview of the various tasks that are involved. The first step is patient registration, where essential personal patient information, along with insurance information, is recorded and checked for eligibility and coverage. 

Next, comes the medical coding. In this step, the medical billing company translates the diagnoses and various procedures or treatments into the standardized codes that insurance company computers understand. This step is critical since any errors at all can lead to claim denials

The next step is claim submission, where the medical billing company will submit the claims to insurance companies to be reimbursed for the services they’ve rendered. This step has the potential for claim rejection, and if a claim is rejected, the billing company will often simply correct the error and resubmit the claim automatically. 

Finally, the last step is the payment posting and any follow-up that’s needed. The billing company will post payments received and will follow up on claims that are unpaid and extend the revenue cycle. They will also usually handle the usual patient billing inquiries, which can range from simple to highly complex, given the intricacies of insurance coverage and individual policy specifics.

Why You Should Consider Outsourcing Medical Billing

Now that you know what a medical billing company does, in general, and on a daily basis, you might be starting to wonder what the benefits are of outsourcing that particular workload. One of the biggest advantages is that it frees up your staff and healthcare provider partners to focus on what they do best: providing industry-leading care for your patients. 

Additionally, specialized medical billing companies like AMS are uniquely qualified to maximize your practice’s revenue and reduce overall error rates for claims. They keep their teams up-to-date on all of the constantly-changing industry regulations and compliance requirements, which helps ensure that your practice will never face penalties for violations or non-compliance. 

Finally, outsourcing your medical billing services can lead to substantial cost savings. By eliminating the need to spend in-house staff time and payroll dollars to manage billing needs, practices can save on salaries, benefits, and even hiring, training, and onboarding. 

Partner With AMS Solutions for Your Medical Billing Needs

AMS Solutions is one of the leading providers of medical billing services and can help you streamline your organization’s billing operations. For more information on the benefits your practice can see, or to get started making the switch, reach out to AMS Solutions today.

May 10, 2023 by AMS Solutions 0 Comments

At AMS Solutions, we understand more than most that dealing with unpaid medical bills can be one of the most stressful, confusing, and even overwhelming tasks, particularly when there are problems with getting the bills paid by your insurer. You may even be at the point where you’re wondering, “Can you sue an insurance company for not paying medical bills?” This question is a lot more common than you may think, particularly when patients may find themselves stuck in a frustrating situation with their insurance providers. 

Understand Your Rights

First of all, you must understand your rights, however, the insurance landscape can be incredibly complex. In some cases, the answer to “Can I sue my medical insurance company” is a definite yes. That said, like many other things it is not as straightforward as it seems. 

Before rushing out to file a lawsuit, however, you’ll need to ensure that you’ve exhausted all of the other possible solutions or remedies. This can include filing an appeal directly with the insurance company, seeking the intervention of an insurance regulator, or even getting a patient advocate involved. 

When Can You Sue an Insurance Company?

If your insurance provider is not adhering to the terms of the contract that they hold with you, your insurance policy, then it is possible to sue for a breach of contract. This is often the case when a particular insurance company denies a claim without any reason, when they’re delaying payment intentionally, or when they refuse good-faith out-of-network rate negotiations as may be required by their policy. The biggest hurdle is that the legal process can be lengthy and quite costly to pursue in some situations. This is where the services AMS Solutions provides can be of incredible value.

The Value of Expert Assistance

When you’re dealing with an issue as serious as unpaid medical bills, expert assistance can make all of the difference in your case. If you’re asking “Can I sue my medical insurance company?”, it may be time to talk to a professional about it. AMS can offer you that much-needed assistance. We are well-versed in the intricacies of insurance policies and have a solid track record of helping to resolve complex billing issues. 

How AMS Solutions Can Help

The expert billing professionals at AMS have extensive expertise not only in coding and billing but in collections. This means we’re uniquely equipped to help you navigate the incredibly complex billing situations that have you wondering if you can sue your insurance company for not paying your medical bills. 

We can help you explore viable solutions, and our team of insurance experts can review your coverage, and help identify any potential inconsistencies in the denial issued by the insurer. For those trying to appeal insurer determinations, this can be invaluable. In many cases, it can even lead to a satisfactory resolution without resorting to legal action. 

The Best Course of Action – Partnering With AMS

Can you sue an insurance company for not paying medical bills? While the answer is yes, it’s important to remember that it should be the last resort. It’s often found to be more cost-effective and more efficient overall. This is generally because the more efficient and cost-effective option is to resolve these issues with the help of experienced and trusted professionals, like the ones at AMS Solutions. 
Instead of feeling overwhelmed by the prospect of legal action against your insurer, why not start with more manageable steps? First, reach out to AMS and let us help you explore your options and find the best solution together.

Healthcare costs and fees concept.Hand of smart doctor used a ca
May 2, 2023 by AMS Solutions 0 Comments

Every industry is rapidly moving toward complete digitization, and the healthcare industry is certainly no exception. Unfortunately, a world that is moving constantly toward more digital solutions will undoubtedly face mounting concerns over growing problems like medical billing fraud. 

We’re going to take a look at what exactly medical billing fraud is, as well as go over a step-by-step walkthrough of how to report it. We’ll also discuss how AMS Solutions is uniquely positioned to be an effective, ethical, and error-free partner in outsourced medical billing. 

What Is Medical Billing Fraud?

Medical billing fraud typically involves false claims or statements being made in relation to healthcare services. This means medical billing fraud can take many different potential forms, including billing for services not performed, double billing, or misrepresenting the services rendered. Fighting these unethical and illegal practices helps to be able to recognize and report instances of medical billing fraud.

How to Report Medical Billing Fraud: A Step-by-Step Approach

  1. Document Everything: The first and most important step in billing fraud reporting is documentation. Keep a record of every detail related to the suspected fraudulent billing. This includes dates, service descriptions, amounts billed, and records of any conversations you had with providers or insurers.
  2. Contact Your Insurance Company: Once you have gathered together all of the needed information and documentation, the next step is to contact your insurance company. They will generally have a dedicated fraud reporting hotline, and they will guide you in their specific fraud reporting process. 
  3. Report To Authorities: If your insurance company doesn’t, or isn’t able to, resolve the issue, or if you suspect they may be involved in the fraud, it’s important to escalate the matter to the appropriate local, state, or federal authorities. This can include the state insurance commissioner’s office, the Federal Trade Commission (FTC), or even the Office of the Inspector General (OIG).
  4. Get Legal Help & Representation: If the fraud has resulted in you suffering financial harm or other measurable damages, you may have the right to pursue compensation, but you’ll likely need to get an attorney involved. Consulting with a lawyer will often not only be able to get you answers to your questions, but it can get you guidance on the process, and may even result in the attorney taking the case on contingency.

Partner with AMS Solutions for a Fraud-Free Experience

Understanding how to report medical billing fraud is a critical skill in the modern highly digital healthcare landscape. By staying highly vigilant, you can help fight this unethical practice, ensuring that everyone pays their fair share for healthcare services. Remember, however, that prevention is the best strategy, and while understanding how to report medical billing fraud is essential, doing everything you can to prevent it is even better.

Partnering with one of the most trusted leaders in the medical billing services industry, like AMS Solutions, can go a long way toward providing you with peace of mind regarding your practice. Choosing a reliable billing partner like AMS means that you can count on your coding, billing, and collections to be handled in a professional, ethical, and legal manner that helps protect patient data integrity and security.
At AMS Solutions, we’re also committed to transparency and integrity in all aspects of our operations. We adhere to all local, state, and federal regulatory requirements, and ensure that all billing practices we engage in are accurate and compliant. We employ a robust checks and balances system to prevent any chance of fraudulent activity, providing a safe and reliable billing service for all of your organization’s needs. Reach out to AMS Solutions today to learn more or to get started making the switch.

Smart doctor hand using calculator for account about medical cos
October 20, 2022 by AMS Solutions 0 Comments

Both Medicare and private insurance plans use many different methods to identify and avoid incorrect or improper payments. The methods and tools used can vary depending on the review type, and whether they are used in the pre-payment or post-payment stage. 

Both are important, but understanding pre-payment review is the first step in understanding the beginning of the payment review process. Pre-payment review in particular can help prevent improper payments, saving money from day one.

What Is Pre-Payment Review?

The Medicare insurance pre-payment review is a simple step in the claims process. It is the review of a claim before it is paid by the insurer. In some cases, the pre-payment review can result in the denial of the payment. The pre-payment process includes medical review as well as the application of edits where needed. An edit can provide automatic verification of certain claim details, even across sets of claims, so make sure they meet the criteria for payment. Edits are applied by processors between submission and payment of claims.

When Is Pre-Payment Review Required?

Pre-payment review is when Medicare, or potentially any private insurer, wants to review all of the claims from a particular office or facility before they pay them.

This often happens when using a doctor, facility, or office that has had a history of claims that resulted in improper payments. In many cases this could be because they’ve submitted documentation that doesn’t support the coding, unnecessary services, billing inconsistencies, and more. Sometimes, payers determine that there is an anomaly in claims that is traceable to other providers in the region.

What Is The Pre-Payment Review Process?

In general, there are two primary types of pre-payment reviews, the complex, and the non-complex. The complex review is going to require documents aside from the claim itself, such as medical records or consultation to review the validity of the claim. The non-complex review isn’t going to require any additional documentation.

There are three criteria on which reviews are based. These are National Correct Coding Initiative edits, edits classified as Medically Unlikely, and Medical Review. Both the National Correct Coding Initiative edits and Medically Unlikely edits will generally be non-complex reviews.

Medical review, however, can be a relatively complex process. It will usually be performed by Medicare Administrative Contractors or Supplemental Medical Review Contractors, and the review contractors will focus Medical Review activities specifically on the already-identified problem areas, and will determine the action to take based on the severity. These actions can include:

  • Pre-payment review
  • Post-payment review
  • Education or feedback for the healthcare provider

If the decision made is to enact pre-payment reviews, the insurer or payer will ask the provider to send pertinent records and other documents for any claims made within a predetermined time frame. In many cases the records period is three month’s worth, but in some rare cases they can go much further back.

Ending Pre-Payment Reviews

To remove pre-payment reviews, providers or coders should first review all of the pertinent medical records and double-check that all codes used are supported by the medical records. Additionally, they should make sure that their billing and coding department is adhering to the requirements of each insurer when actually assigning codes or creating billing claims. Coding and billing staff should also be trained to properly check for bundling and unbundling of codes.

AMS Solutions Can Help Prevent Pre-Payment Reviews

When it comes to preventing or avoiding pre-payment reviews, AMS Solutions can provide coding and billing professionals that are kept up-to-date and completely educated on all aspects of claims billing.

Doctor working with digital tablet and laptop computer with smar
October 10, 2022 by AMS Solutions 0 Comments

What Is Concurrent Review By An Insurance Provider?

Many people wonder what the standard concurrent review definition is. A concurrent review is a review that takes place while the patient is actively receiving care during an admission to a healthcare facility. The concurrent review’s purpose is to have some framework for oversight during treatment that allows examination and scrutiny of the type of care that is being administered to the patient. It also evaluates the necessity for that level of care, as well as the setting.

Why Are Concurrent Reviews Needed?

The goal of concurrent reviews is to make sure that healthcare is delivered effectively and efficiently, to reduce or prevent the improper use of inpatient medical services and treatment, and to ensure that all patients receive the high quality of care that is indicative of inpatient treatment. It works similarly to prior authorization, in that the concurrent review can help foster more effective communication about the patient to various areas or departments of the healthcare organization itself. 

Additionally, concurrent reviews also help provide access to other health services and support features that may help with the coordination or continuation of care, particularly in regard to transitions from one level of care to the next. This may be either discharged to a care facility, or even to their home. A concurrent review is also able to identify patients that may benefit from various care methods, including case or disease management, or any number of other options depending on the diagnosis and treatment needs. 

The Concurrent Review Process

The concurrent review process is designed to optimize care during a hospital or treatment facility admission. The goal is to ensure that the patient receives the right care, right when it’s needed and that the treatment is in line with the insurance plan and coverage requirements. The concurrent review process includes aspects such as:

  • Collection and aggregation of all patient information directly from the care team regarding their condition and progress in treatment
  • Evaluating patient treatment information from the care team to determine treatment coverage
  • Maintaining informative communication between all parties involved in the patient’s care when a decision regarding coverage is made
  • Identifying situations when patients may be given a discharge and continuing care plan early in the stay
  • Continual evaluation and assessment of the care plan during the stay
  • Identifying and referring any potential concerns about the quality of care or patient safety that may require additional review

Concurrent Review vs. Peer Review

A concurrent review is functionally much different than a peer review when it comes to the process by which they happen, as well as the goal of each. The concurrent review process is an ongoing process that should be happening seamlessly as a part of all levels of care for an insured individual. 

The peer review process, however, is meant to address specific and often highly complex treatment needs on an ad hoc basis. This process consists of any current treating practitioner submitting a request to consult with a medical health professional within the insurance company. Often this is to discuss a utilization issue or to go over needed care that may be required for long-term care services and other continued care support services.

AMS Solutions Can Optimize Your Coding For Review

One of the biggest factors in ensuring your organization is paid promptly and correctly is leveraging expert billing and coding professionals. With more than 30 years of experience in the billing, collections, credentialing, and practice management fields, you can trust that AMS Solutions will be an effective coding and management partner. 

October 5, 2022 by AMS Solutions 0 Comments

If a healthcare patient’s claims are denied, not only will they often wonder why claims are not being processed, but they may still submit claims that are inaccurate. Here are some of the common reasons that claims are denied.

Top Reasons Why A Claim Is Not Being Processed

Missing Or Incomplete Patient Info

An incredible portion of claim denials are administrative or clerical in nature and originate at the front desk. This means things like patient data oversights, such as a missing patient subscriber number, missing date of birth, and incorrect insurance eligibility are all routine reasons that a claim is denied. 

Basic Claim Form Errors

A huge portion of claim rejections is known to be caused by “simple errors” in either the patient data or in the procedure codes. This can be something as simple as a misplaced letter in the last name, or a patient ID number having two digits transposed. These errors are usually very quick and easy errors to fix, but they stretch out the revenue cycle, so they should be avoided if at all possible. 

Lack Of Official Documentation Supporting The Claim

Claims that have a component of medical necessity will need documentation or records that support that designation. In situations like this, the payer will often require additional support documents that not only illustrate medical necessity but also support the level of service.

Insufficient Medical Necessity

Even when substantial amounts of documentation and medical records are provided, occasionally a payer will simply decide that a procedure or treatment isn’t medically necessary. This can be a difficult situation for everyone involved, but in some cases, it can be avoided. 


The best way to fight insufficient medical necessity denials is to have good communication between your clinicians and coding staff. When a claim is denied, for this reason, the doctor’s office or provider may be forced to absorb the treatment cost, or they may be able to collect the full amount from the patient, which isn’t very likely. 

Pre-Authorization Or Pre-Certification Was Not Obtained

There are many situations that warrant getting pre-authorized to perform some type of care. Knowing which insurers require pre-authorization and what they require to authorize coverage is essential for your coding and billing team. Depending on what coding or billing software is used, there may even be built-in measures for highlighting certain procedures and special insurers.

Claims Filed After Deadline

With all of the different insurers out there, it’s no surprise that many of them have different deadlines for submitting claims, and have varying degrees and policies for exceptions when deadlines are missed. Some payers can fix a missed submission with a quick phone call, while others will require a more clerical and administrative fix by having you fill out some paperwork to get the issue fixed.

The Provider Used Was Out-Of-Network

Insurance companies and their networks can change drastically from one year to the next, and while many patients don’t realize it, this includes the various doctors and healthcare providers they have partnered with. To be sure that claims, benefits, and payments are made in full for your treatment and doctor’s appointments, use a doctor or facility that is in-network. While this may not mean that everything is covered, significantly more of the services that you need will be able to be obtained in this way. 

Prevent More Denials With AMS Solutions

Your billing matters and claims denied for simple and preventable mistakes. Ensure that your medical billing support is all properly trained in the methods that your biggest payers require by partnering with AMS Solutions.

Contact Us

"*" indicates required fields

Terms of service
This field is for validation purposes and should be left unchanged.