Delays and Denials – A Preventable Problem

Not providing proper documentation is one of the top reasons a billed charge is delayed, or even denied, by an insurance company. Not including critical information such as the correct client name, client information, or the documentation necessary when requesting higher levels of care or longer lengths of stays can not only cause delays or denials, it increases the staff hours necessary to locate the information, update, and resubmit the claim.

Worse yet, if necessary testing and the justification for the care level and length of stay wasn’t properly documented at the time, there is no way to do the testing or retrieve this information now. The result could be that all or a portion of the claim may be denied, severely impacting the financial health of the recovery facility.

Because insurance companies determine what level of care will be authorized based on medical necessity, the documentation provided must be thorough and accurate. The center must validate why the requested level of care is more appropriate for a client than a less expensive option.

The answers to questions such as these must be documented at the time of testing, evaluation, or admission.

  • Is the client presenting concerning conditions or behaviors?
  • Is the client in need of detox services?
  • Does the client appear to be under the influence?
  • Do they need to be monitored by a physician?
  • What tests have been performed and what are the results? (blood test, UA, blood pressure, etc.)

If not documented properly, payment for incomplete claims may never be made to the facility.

In many facilities, a major contributor to delayed or denied claims is misusing or underusing the center’s EMR. Inspira’s state-of-the-art billing engine has the capability of pulling data directly from two of the most commonly used EMRs: KIPU and Best Notes. This allows your center to get better and better at documentation, so that your staff doesn’t miss collecting and documenting important information.

Better documentation leads to fewer delayed or denied claims, resulting in more timely payments and less staff time for research and resubmittals.

Should a claim result in a denial from the insurance company, Inspira handles all of that for you. You do not have to use your limited staff time to research and resubmit the claim. Inspira will determine the reason for the denial, attempt to resolve it by gathering updated documentation, and re-submit a claim. As needed, Inspira will handle any appeals or negotiations with the insurance company on your behalf.

Insurance companies can hold or delay payments by placing a facility under audit, especially if a facility has gained a poor reputation by continuously providing inaccurate documentation. Some centers have between $1 million and $10 million on hold at any given time. In addition to individual carriers taking action, a state’s insurance commission can levy fines or conduct audits.

 

Denials

 

One of the most common complaints we hear about other billing companies is that they only collect on the claims that are the easiest and most recent. Old claims are often ignored, forcing facilities to write off massive amounts of uncollectible debt. Similarly, difficult or obscure insurance companies might have their claims ignored or underworked.

Inspira can help you with aged Accounts Receivable (A/Rs) by going back through older claims and processing everything you are owed. This often results in hundreds of thousands of dollars (or even millions) in “found” money, sometimes from checks that were lost in the mail or issued to the wrong provider.

Every unpaid claim Inspira has billed for you is tracked and managed carefully so that you receive all of the payments owed to you.

Your Inspira personalized Dashboard, accessible online anytime, tracks each claim, including the details of a denial. This portion of the dashboard shows:

  • Information on specific line items of the claim
  • The reason for the denial
  • The status of each denial as it is tracked and managed, including the status of any appeals

If a claim, or even a portion, is denied, Inspira assigns a service representative to analyze, track, and resolve the claim. These representatives are held to a high performance standard and their work is monitored carefully each week. Because Inspira was founded by banking professionals, we understand that money is to be treated as a precious commodity. So, unlike many other billing companies, we are not afraid to go after the ‘hard to collect’ money.

Inspira works very hard to collect all of the money that you are owed so that your business stays financially healthy.

With Inspira doing the heavy lifting for you, you’ll never have to leave delays and denials to chance. Through better documentation and real-time claim monitoring, you will get paid faster for more of your claims, leading to higher efficiency and increased revenue.