Altruis explains how to process rejections and denials that happen during the FQHC billing reimbursement phase.
FQHC billing can be challenging. Even the most competent and compliant healthcare provider faces reimbursement rejections and denials. It’s just part of providing medical services in the complex world of U.S. healthcare. But, having the right FQHC billing services can make the difference.
As a Federally Qualified Health Center (FQHC), your organization could be missing out on valuable reimbursements for the services you provide. Misunderstandings about rejected and denied reimbursements are quite common and can cost an FQHC thousands or even millions of dollars per year.
This article looks at the difference between rejections and denials, plus why the distinction is so important. We’ll also address methods to more effectively manage the revenue cycle and maximize reimbursements.
What’s the Difference Between a FQHC Billing Rejection and a Denial?
The terms denial and rejection are often used as synonyms in medical billing. Even a practice’s most experienced manager or medical biller might casually use the two terms interchangeably.
When it comes to processing the claims, the difference matters. Below is a breakdown of the main similarities and differences between rejections and denials in medical coding with FQHC billing.
Rejection
A rejected claim is one that has never made it through the Centers for Medicare & Medicaid Services (CMS) claims and adjudication system. It was rejected early in the process and is not even considered received by CMS or other payors.
A rejected claim is also not considered a billed claim, in terms of its status related to the beneficiary. When a provider is notified of the rejection, there’s an opportunity to correct the error or add the missing information, then resubmit the claim to move it along in the adjudication process.
Denial
A denied claim has made its way through the adjudication process and a determination has been made by the payor. It was denied instead of rejected or accepted, which means payment will not be remitted.
Still, there is an opportunity to appeal a denied claim and request information about what types of modifications or documentation could be added to overturn the denial. The fact that denials can be appealed is what commonly causes confusion. To distinguish between rejections and denials, remember: Rejections are resubmitted and denials are appealed.
If a denied claim is appealed and the appeal is still unsuccessful, the claim remains at denied status. Thus, it is non-reimbursable, at least via the initial payor in question.
FQHC Billing Rejections vs. Denials: A Risky Scenario
Why is it so important for a medical provider to differentiate rejections from denials? Let’s examine a situation where it’s extremely important. This scenario plays out in hundreds of healthcare practices across the country.
A busy FQHC healthcare practice receives daily acknowledgment reports with long lists of rejected and denied claims. However, the practice is currently overwhelmed and understaffed, so no one is tasked with addressing these reports.
Finally, a manager at the practice glances at the list of reports, sees “rejected,” and thinks “denied.” This person recognizes that working denials take significant effort. They realize that focusing on billing out the current claims with her overwhelmed staff is all that they can handle, so they just continue ignoring the reports. For these reasons and more, a FQHC billing provider is vital to cleaning up such common issues.
Eventually, this medical practice hires a new billing specialist to look over their massive queue of backlogged claims. The new, highly-trained biller realizes that their rejected and denied claims are intermingled and should be separated to follow two discrete action plans.
The new biller also looks at the dates involved and determines that so much time has passed, some rejections and denials are about to become ineligible for reimbursement due to timely filing. The practice stands to lose a large chunk of revenue.
Immediately, the new biller reviews and resubmits all eligible rejected claims and successfully appeals denied claims that are still within the window of potential reimbursement. They also implement billing tools like RetroPayTM to recapture past reimbursements that were never sought because the patient was thought to be uninsured. The new biller ultimately saves the practice from losing hundreds of thousands of dollars in rejected/denied reimbursements, plus they add in recaptured revenue by identifying retroactive coverage for the uninsured.
Verification Checklist for Medical Billing
To facilitate timely and thorough billing reimbursements, here’s a helpful checklist of items to look over during the claims process.
- Missing information. Ensure there are no blank fields, missing modifiers, incorrect plan codes, or incorrect/missing social security numbers.
- Duplications. Look for duplicate claims and any duplicated information.
- Eligibility. Is the patient eligible for services? Are they confirmed to be eligible to participate in Medicaid vs. Managed Care Medicaid, for example?
- Network. Check to see if the services from a participating provider are considered in or out of network.
- Coverage. Double-check Medicare coverage, third-party resources, and so forth.
- Coding. Is the coding completely appropriate and valid?
- Timing. Ensure the deadline for filing has not passed.
Tips for Reducing Rejections and Denials
Remember, rejections and denials are a part of medical coding and billing, but they can be minimized to save time, money, and hassle. Here are some helpful tips for handling the process most effectively.
Timely Action
Work rejections daily to ensure that the claims are received by the payor. Focus on any outstanding denials by starting with those about to reach Timely Filing limits to ensure the opportunity for reimbursement.
Training
Make sure the person/service handling your FQHC billing is thoroughly trained on accurate coding and industry best practices.
Education
Educate your team on new billing and coding trends, or work with a reputable billing partner that always stays fully up-to-date on the latest news in the field.
Hygiene
Practice good data hygiene, which means keeping your processes clean, streamlined, and mostly free of issues like errors and duplication.
Automation/Technology
Automate the basics of the process to eliminate human errors, but still have a person empowered to monitor the process and ensure nothing falls through the cracks. Explore technology and analytics that help limit rejections and denials.
Altruis: FQHC Billing Expertise and Customized Support
Altruis provides next-level FQHC billing services that are a step above the traditional approach. Our team of experts examines your practice’s medical billing processes from end to end, then recommends optimization options for profitability.
Altruis is much more than just a billing platform. We’re your full-service partner in savvy revenue management. Through thriving partnerships, we maximize medical practice potential.
