Top 5 reasons for denied claims in home health billing and how Cliniqon can help address them

Mar 2024

Denied claims are often a significant challenge for home health providers. They can disrupt financial stability, impact the ability to deliver uninterrupted care to patients, and strain operational resources. Partnering with Cliniqon offers home health providers a strategic approach to address the challenges that denied claims present. We utilize our expertise in revenue cycle management and technology-driven solutions to reduce the likelihood of claims denials and maximize reimbursement. In this blog, we explore the top 5 reasons for denied claims in home health billing and how we can help address them:

Missing or Inaccurate Information

Misspelled patient names, incorrect dates of service, misinterpretation of medical codes, inaccurate insurance policy numbers, incomplete documentation of services rendered, or any other missing or inaccurate information can lead to denied claims and result in financial losses for providers. Therefore, home healthcare companies must ensure that all claims’ submissions are accurate; however, they often find this challenging due to frequent changes in healthcare regulations, lack of standardization, human error, and resource constraints.

How Can We Help?

Cliniqon implements robust processes to verify the accuracy of all information before submitting claims, ensuring compliance with regulatory standards and maintaining the integrity of the billing process. We utilize claim scrubbing tools to review claims for errors, conduct quality assurance checks to review claims data for accuracy, establish clear protocols for documenting procedures performed, diagnoses assigned, and other relevant information, and provide staff training to ensure that they implement the best practices for accurate documentation

Coding Errors

Coding plays a vital role in accurate billing and reimbursements. Correct coding guarantees that home healthcare providers receive proper reimbursement for their services. Despite this, coding errors remain a persistent issue for home healthcare providers, often leading to denied claims and financial setbacks.

How Can We Help?

Cliniqon employs various strategies to help address coding errors. We incorporate continuous education and training programs for our coding staff to eliminate undercoding, upcoding, incorrect code selection, modifier errors, mismatched codes, invalid codes, duplicate billing, failure to update coding practices, and coding for unnecessary services. Moreover, we ensure that our home health coders are up-to-date on coding guidelines and regulations. Additionally, we conduct regular audits of coding processes and double-check all codes to promptly identify and rectify errors.

Failure to Obtain Prior Authorization

Prior authorization is crucial in ensuring whether a patient’s insurance covers a medical treatment, service, or drug. However, failure to obtain prior authorization can lead to the claim being denied, delayed, or only partially approved with low reimbursement rates. Providers often struggle in the prior authorization process due to ever-changing payer rules, lack of transparency from payers, administrative burden, benefits and eligibility gaps, and using outdated technology. Providers need to address these challenges to avoid claim denials, ensure the continuity of patient care, and improve reimbursements.

How Can We Help?

At Cliniqon, we have dedicated teams with expertise in payer regulations and authorization requirements, which allows them to manage the authorization process efficiently. We conduct insurance verification and utilize comprehensive clinical documentation, advanced technology, trained staff, and effective communication channels to facilitate the prior authorization process.

Late Claims Submissions

Submitting claims after the designated timeframe set by the insurance company is one of the top reasons for claims denials. As a result, healthcare providers risk losing reimbursement for services rendered.

How Can We Help?

We not only prioritize timely claim submissions but also prioritize accuracy in our approach. Our team ensures that each claim is promptly filed after being carefully reviewed. We utilize standardized procedures for claims submission and set clear deadlines for each step in the process to avoid delays. Moreover, we continuously track the status of submitted claims and follow up with payers if any delays or issues are present.

Duplicate Claims

Duplicate claims can occur due to technical glitches in billing systems, human errors during manual data entry, lack of integration between different systems, or miscommunication between healthcare providers and billing departments. These errors can lead to denied claims, impact the revenue stream of home healthcare providers, and create frustration for patients who may experience delays in receiving their services.

How Can We Help?

Our Home Health Billers are well-trained and experienced in advanced billing software, which enables them to detect and prevent duplicate submissions before claims are finalized. Moreover, they also conduct regular audits to identify problems with the claims submission process.

Final Thoughts

Don’t let denied claims jeopardize your home health agency's revenue, operational efficiency, and patient experience. Entrust Cliniqon with your home health billing process to minimize claims denials from missing or inaccurate information, coding errors, lack of prior authorization, late claims submissions, duplicate claims, or any other issues. Our denials management process not only addresses these challenges but also prevents future claims rejections. Partner with us to safeguard your agency’s success with our expert home health billing solutions.