Navigating the complexities of medical billing claims is a significant challenge for many small and mid-sized healthcare providers. Among these challenges, claim denials stand out as a particularly frustrating issue, often leading to delays in reimbursement and financial strain. These denials not only affect the financial health of medical practices but also impact patient satisfaction and trust. 

The foundation of lowering your organization’s denial rate is understanding why medical billing claims are denied, and then having actionable ways to fix those issues. In this post, we’ll look at the most common reasons behind claim denials and how AMS Solutions can help in effectively managing and reducing these occurrences.

Understanding Medical Billing Claim Denials

Medical billing claim denials can be a significant source of operational and financial inefficiency for healthcare providers. A claim denial occurs when an insurance company refuses to pay for a medical service, often due to errors or discrepancies in the billing process. These denials can happen for various reasons, ranging from simple administrative oversights to more complex issues like coding errors or misunderstandings about insurance coverage.

The frequency of claim denials in the healthcare industry is a major concern. Not only do they lead to delayed or lost revenue, but they also require additional resources to rectify. This can create a cycle of administrative burden, diverting attention from patient care to paperwork. Understanding these denials’ root causes is the first step in developing strategies to minimize them, ultimately leading to a more efficient and financially stable healthcare practice.

The Most Common Reasons for Medical Billing Claim Denials

Identifying the primary causes of medical billing claim denials is crucial for any healthcare provider looking to improve their billing processes. Here are some of the most common reasons for these denials:

• Coding Errors: Incorrect or outdated procedures and diagnosis codes can lead to denials. These errors may stem from simple data entry mistakes or a lack of understanding of the latest coding standards.
• Incomplete Patient Information: Missing or inaccurate patient details, such as name, date of birth, or insurance policy numbers, can result in a claim being rejected.
• Service Not Covered by Insurer: Sometimes, a claim is denied because the service provided is not covered under the patient’s current insurance plan. This often occurs due to misunderstandings or lack of verification of the patient’s coverage.
• Lack of Prior Authorization: Many insurance plans require prior authorization for certain treatments or procedures. Failing to obtain this authorization can lead to denials.
• Duplicate Claims: Submitting multiple claims for the same service can trigger a denial, often due to confusion or errors in the billing process.

Preventing Medical Billing Claim Denials

To mitigate the issue of medical billing claim denials, healthcare providers can adopt several key strategies:

• Ensure Accurate Coding: Keeping up-to-date with the latest coding standards and conducting regular training for coding staff can greatly reduce errors.
• Thorough Patient Data Collection: Rigorous collection and verification of patient information can prevent denials due to incomplete or incorrect data.
• Understand Insurance Policies: Familiarity with the various insurance policies and their specific coverage details is crucial. This includes verifying patient coverage and understanding the requirements for prior authorization.
• Regular Claim Audits: Conducting regular audits of the billing process can help identify and rectify common errors leading to denials.
• Leveraging Technology: Utilizing advanced billing software can streamline the billing process, reduce errors, and ensure compliance with current regulations.

Trust AMS Solutions to Navigate and Resolve Your Medical Billing Claim Denials

Partner with us to transform your billing challenges into opportunities for growth and success, and focus on what matters most, your patients. Our specialized approach ensures accurate, timely, and compliant billing, reducing denial rates and enhancing your financial stability. Contact AMS Solutions today for expert guidance in overcoming medical billing claim denials.

When it comes to making money as a healthcare provider, you’re going to need to know how much to charge for the services you provide to your patients. This is a pretty big part of your day-to-day business, so it only makes sense to be educated on how to determine charge amounts as a health care provider.

Why is it Important to Know the Right Charge Amount as a Healthcare Provider?

The pricing of services is one of the most important factors in determining the success of a healthcare business. It is also important for healthcare providers to understand their charge amounts as it has a significant impact on their revenue and profit.

Charge amount: Charge amounts are the fees that a healthcare provider charges to its patients for services rendered. They are usually paid in advance and are not refundable, unlike co-pays.

Pricing strategy: Healthcare providers use different pricing strategies to determine how they want to price their services. They can either use cost-based pricing, value-based pricing, or competitive-based pricing.

Cost-based pricing models: Cost-based pricing is based on the cost incurred by the provider for providing care for a patient and this type of strategy can lead to higher payouts. 

What are the Different Pricing Strategies for Healthcare Providers?

The pricing strategy can be a major factor in the success or failure of a company. Pricing strategies are not only limited to retail stores but also healthcare providers. Healthcare providers use different pricing strategies to either improve the customer experience, increase revenue, or both.

The healthcare industry is one of the most competitive industries which is why many companies have come up with different pricing strategies to stay competitive and make more money. The ways pricing is done in the healthcare industry are:

• Price by service (surgery, medication)
• Price by time (per hour, per day, per procedure)
• Partial price disclosure
• Price by usage

Every healthcare provider is different in how they decide to charge their patients. Some are able to charge what their services are worth and others need to rely on government reimbursement rates which can be lower than the cost of providing the service.

What Happens If You Under or Overcharge Patients?

There are consequences for under- and overcharging patients. Healthcare providers should be aware of these consequences as they learn more about providing health insurance for their patients.

Undercharging patients: If a doctor charges less than what they should, they are essentially giving away their services. This can lead to a shortage of medical professionals and more people going without care. It also leaves doctors with less money to use for their business, which can lead to them closing up shop.

Overcharging patients: Overcharging patients is considered unethical because it is taking advantage of their situation and could cause them financial hardship. This can also lead to a loss of trust from the patient and make them hesitant about returning for future care or even recommending that doctor to others.

How to Determine the Right Charge Amount for Your Services as a Healthcare Provider

There are a few factors that you should take into consideration when determining the right charge amount for your services as a healthcare provider.

• What is the average price of your service in the market?
• How much do you need to cover your expenses?
• What is the average cost for your healthcare services?
• What is the target clientele?

AMS Solutions can help healthcare providers with determining appropriate charge amounts for their practice. Contact us today if you need help with charge amounts, or any other health insurance issue. We can also help with managing your medical practice. 

Getting a recoupment request can be scary and worrisome. Recoupment is a provision in most health insurance policies that allows the insurer to request a repayment of some or all of the cost of care after it has been provided. Most insurance companies have this provision, but it is not often used. 

Companies may also request repayment for certain services when they do not agree with the treatment they provided. There could be disagreement over in-patient and outpatient treatment, as well as disagreement over the use of imaging services and lab tests that were provided. 

If you need help with combatting a recoupment request, you may want to seriously consider getting a medical biller to help with the appeal process. 

What Exactly Is Recoupment?

As aforementioned, recoupment is a term used in the insurance industry to describe the process of recovering money from a third party.

The term is most commonly used in reference to health insurance, but can also be applied to other types of insurance policies. In the insurance industry, recoupment is a process wherein an insurer recovers money from a third party. 

This process can come as a result of either legal action or voluntary payment. Recoupment is often used to cover losses that occurred due to an accident between two parties. Hiring a medical billing company can help you fight any recoupment request. 

Common Reasons for Recoupment Requests

The recoupment process starts with a written request for repayment. This will be accompanied by a phone call or email to alert the medical insurance provider that there was an error. 

Just about every insurance company will give you up to 30-60 days to take action once the initial request has been sent and delivered. There are many reasons why a recoupment request can occur. 

The most common reasons for recoupment requests are:

• Duplicate payments for the same service code/date
• A duplicate claim was submitted in error
• Payment sent to an incorrect healthcare provider
• Payment for a service that happened after the patient’s insurance plan expired
• Payment made for a supply or service that was not covered in the patient’s insurance plan
• The insurance claim was paid for an ineligible beneficiary 
• The patient’s total deductible was miscalculated

How To Fight A Recoupment Request 

As a healthcare provider, there are ways you can fight a recoupment request if you believe it’s not valid. One of the first steps you need to take is to ask for all relevant documentation from the insurance company relating to the patient’s claim and the recoupment request. This ensures that you have followed guidelines by verifying the payment against established contract guidelines.

If you have received a contested recoupment request, it’s important to get in touch with your state insurance commissioner as soon as possible. The state insurance commissioner is the best person to ask about the rules and regulations for this type of situation.

There are some states with firm timelines for recovering returns which can affect how the process goes if a breach of contract occurs later on. When analyzing these documents, be sure to look for those areas where the breach happened. It’s crucial to assess which party should be responsible for the compensation and know how much of the agreement needs to be fulfilled financially.

Avoiding Recoupment Requests

The practice of recoupment is typically done by collecting money from the patient or their family. There are many ways to avoid this situation, but one of the most important things to do is to hire a medical billing company for your office. They will not only handle all the billing, but they will also make sure that you don’t get any recoupment requests in the future.

This is where AMS Solutions comes in. The best medical billing company in Texas is AMS Solutions. We have over 20 years of medical billing experience and know exactly how to maximize your profits as a healthcare provider.  

Get a free practice audit today! 

You can also call us at 214-522-0210 or email us at info@ams-solutions.com. 

Medical bills are something every person encounters. However, when you’re a healthcare professional running a business, medical bills need to be collected promptly to receive payment. 

One thing is for certain: as a healthcare professional, you shouldn’t deal with collecting 

medical bills on your own. The smartest way to deal with medical bills is to find a trusted medical billing company that can help sort out your finances appropriately

The best medical biller for you will be someone who can make sure you’re getting the most revenue out of your business. Medical billers want you to get paid, and it’s their job to take care of any roadblocks that are in the way of you receiving payment, whether it’s due to an insurance claim hold-up, or a patient who doesn’t have enough funds to pay up. 

How Long Are Medical Bills Collectible For?

Based on the data available on the official US census website, about 19% of America won’t be able to afford to pay medical bills right away. Non-paying patients are an aspect every healthcare professional has to deal with at one point in their career. When you have patients who haven’t paid the balance due on their account, you’re probably wondering, how long is a medical bill collectible for?

Medical bills are collectible for a period of 30-180 days. The amount of time a doctor’s office will attempt to collect payment from a patient depends on the amount of the outstanding balance and standard practice procedures for collecting late payments. 

It’s at the doctor’s office’s discretion when they decide to hire a collection agency to take care of the patient’s account. If it’s a long-time patient, the office may be more willing to work with them. If it’s a one-time patient who keeps missing appointments, the office may wait a month after initiating contact and then send it straight to a debt collector. 

What Are Reasons Why A Medical Bill Isn’t Collected?

Receiving a medical bill as a patient can be daunting. When a medical bill fails to be paid, it’s always because of the patient. The multitude of reasons a medical bill will be left unpaid is because:

• The patient couldn’t pay for services
• The patient refuses to pay for services rendered
• The patient found a coding/billing error
• The patient doesn’t understand the bill 

Patients don’t always ask the questions they should be asking, so it’s up to the medical biller to make sure the patient understands that they:

• Owe a balance 
• Understand why they owe that balance
• Understand they have options when it comes to paying that balance

Clear communication with patients about the bills they owe can reduce the number of payments that go to a collection agency. Any outstanding medical debt is collectible as long as the patient is willing to pay something. 

How You Can Reduce the Impact of Medical Debt on Your Practice

A professional billing company can prevent the harmful impact medical debt can have on your practice. Professional billers can contact patients for a follow-up call, send any outstanding bills to collection agencies, and work with patients on a payment plan when needed. A lot of patients who can pay aren’t aware that they don’t have to pay the whole amount.

Before sending a patient’s account to collections, a reputable medical biller will attempt to see if the patient can pay anything on their account. Even the smallest amount can prevent an account from going to collections. 

There are solutions to prevent ongoing problems with patients who don’t pay up. Only a medical billing company can perform the necessary services to make sure you’re receiving what is owed for the healthcare services provided.

The Best Ways To Deal With Medical Debt As A Doctor

Although we love to think that all patients will always be considerate enough to pay the balance on their account, the real truth is patients can easily neglect a medical bill. Many patients are unaware that billing departments are more than willing to work with them.

Don’t opt for dealing with unpaid medical balances by yourself since you’ll only end up with a pounding headache. As a healthcare professional, it’s important to manage your time wisely by hiring a medical billing company. 

Luckily, medical billing companies know how to start the process of getting the money owed to your practice. Schedule a meeting with a medical billing professional to see how they can help keep your medical office’s finances in check.