Prompt Payment Appeals: Saying “What is Taking So Long” in Optimal Wording

Ah, Rejection. You try not to take it personal. After all, you can resubmit. But there is that little step in between that just fails to inspire interest. Research.

Yes, the steps in working your claim rejection report look like this: Rejection. Research. Resubmit. However, the chore of working the claims which show up on a claim rejection report can be a top office procrastination area.

Rework is never as simple and clear-cut as working fresh claims. Rework can even make your productivity tank for the day. Still, rejected claims can’t be ignored without financial impact. And with ICD-10 still impacting data entry and coding assignment accuracy, your rejection numbers are also a key performance measurement. So grab a cup of coffee and try to make the most of it. Here are a few suggestions to making the Three R’s of Working Your Rejection Report a little more like righting the wrongs of the day.

Know What A Rejection Is and Where It Goes – According to an article written by Sou Chon Young of Hayes Management Consulting, some organizations do not make a distinction between rejections and denials and, as a result, have poor routing of rejections within the revenue cycle. A rejection usually involves a claim that has failed to successfully process through the electronic submission process often due to missing or unrecognizable data elements. By contrast, a denial is usually issued for claims that successfully processed electronically but did not meet coverage requirements. With rejections, the claim recipient (usually a clearinghouse or payer) typically has no claim on file in the system because the submission failed. The difference is essential to the routing of these claims since rejected claims need to be corrected and resubmitted while denied claims need to be reviewed for appeal potential. If there is a problem with your rejected claims routing, fix it. It is sure to save time and money down the road.

Self-Assess For Root Causes – There will be some simple issues – missing information or keystroke errors. Redirect these to the coder for immediate resolution. However, have your coders self assess for root causes to encourage accountability. You might give them some type of rejection scorecard which has them identify a root cause for each rejection, such as “miskey”, “lack of access to needed data” or “auto population issue.” Coders will be the best source of suggesting root cause descriptors. Tracking root causes forces a second or two of reflection on what went wrong which could lead to improved performance. Self-assessment scorecards also provide another communication tool between staff and management regarding data accuracy concerns and suggestions.

Research – Rejection reports can come from different sources – internal scrubbing software, third party billing software, clearinghouses and payers. The detail in the report may vary, also, and may or may not offer remedial steps. Rejections related to eligibility and coverage – patient not identified, procedure/diagnosis mismatch or a generalized “does not meet payer requirements” codes often require research. These claims require some sleuthing into the actual documentation to see if there are data collection errors. Anytime a data collection error is discovered, it is important to think in broader terms. Did this error affect other claims and/or other processes within the record? Could it reappear if not corrected in source documents/integrated software?

Identify Training Opportunities – Rejection reports may be a key tool in identifying coders who require additional training or training areas which might benefit the entire team. For coders with higher rejection rates, an educational action plan should be tailored to the coders’ specific needs. Be sure and consider assigning mentors to less experienced coders. Mentors may be able to quickly review the less experienced coder’s rejections and provide input into performance improvement.

Celebrate Success – Use clean Rejection Reports as a way to communicate praise. Consider incentives for consecutive “no rejection” days and find ways to let your high performers know that their attention to detail is valued.

Set Rejection Policy and Procedures – Consider implementing a “close watch” policy on resubmissions. Did the claim successfully process on the second try? The last thing you need is for any reworked claim to be resubmitted with new, but still bad, information. The clock is ticking so make sure you have a policy which ensures prompt attention to problematic claims.

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