Challenges and Solutions: Handling Insurance Denials in Endocrinology Billing

Endocrinology is a branch of medicine dealing with the endocrine system and its related disorders. It requires a thorough understanding of the various hormones and their functions. The endocrine system regulates vital body functions, including growth, metabolism, reproduction, and mood.

Properly handling denials in Endocrinology Billing is important to ensure that patients and healthcare providers are supported adequately.

Denials in endocrinology billing

Endocrinologists diagnose and treat hormone-related conditions. However, denials in endocrinology billing can be challenging due to the complex nature of endocrine care services.

In this blog we will explore some of the challenges faced in endocrinology billing services, types, common reasons for denials, and more.

Let’s look at the top reasons driving the number of denied claims and how these can be rectified:

Challenges in endocrinology billing services

Some challenges arise in medical billing services, specifically in endocrinology.

Endocrinologists provide medical care for patients whose diagnoses and treatment plans are complicated. This is why it becomes important to properly bill for these services to ensure the least claim resubmittals.
Many endocrinology procedures are considered exploratory or experimental, so insurance companies will likely not cover the costs of these services. This is one reason for denials in endocrinology billing, which creates problems for patients and medical providers.
Inconsistency in endocrine illness coding makes keeping up with the recent changes a challenge.

Types of denials in endocrinology billing

Denials in endocrinology billing can stem from even the slightest typos or errors, specifically if you miss important medical codes. The causes for denials in medical billing are many, however, most of these fall under the below-mentioned 5 categories.

1. Soft denials

Soft denials are interim or temporary and do not require appeals. You can get reimbursements if you take the corrective measures suggested by the payer.

2. Hard denials

Hard denials require appeals and can result in being written-off or lost revenue.

3. Preventable denials

Such denials occur due to insurance ineligibility, invalid codes, or registration inaccuracies. Preventable denials can also be categorized as hard denials.

4. Clinical denials

Clinical denials occur due to missing payments for medical necessities, and these denials do require appeal.

5. Administrative denials

Administrative denials are soft denials that are notified to healthcare providers by the payers. Payers mention the reasons for denial while returning the claim.

How does denial management work?

To overcome billing challenges and denials, a simple process of identification, management, and monitoring makes denial management easy. Let’s discuss the denial management process in detail:

1. Identification

Managing denials in endocrinology billing can only give the desired results if you know and understand the root causes. It is also helpful that payers often mention the reason behind the rejection. The reason mentioned is known as the claim adjustment reason code (CARC). Understanding CARC, or essentially the reasons behind claim denials, is the primary process in denial management.

In identification the denial management professionals try to understand the reasons of denials – then determine and lay down the steps to get reimbursement.

2. Managing

After successfully identifying the root causes of denials, the next step is managing them to generate revenue. The denial management experts can thus create a plan of action for resubmitting the claims for reimbursements and successfully handling appeals on denied medical claims.

3. Monitoring

Denial management professionals arrange the denial records according to the data received. The entire denial management work is audited in the monitoring stage. Here, offering proper technical support and ensuring that all team members are provided the necessary resources is also a part of the monitoring process.

What is important here is that denials can be easily prevented if you know their common causes. Analyzing rejection and denial trends is the most powerful method for identifying these common causes.

4. Prevention

Once you have all the information on claims, the final step of denial management is to kick off a prevention campaign. Prevention involves properly coordinating with all teams to avoid errors while submitting the claims. The denial management team needs to work with the front desk and back-office support staff.

Note:

Understanding the denial management process and identifying where to retain staff, leverage technology, or manage workflow is important.

Mistakes to avoid in endocrinology billing services

When dealing with endocrinology medical billing, it is easy to make mistakes. It takes time and effort to completely understand all rules and regulations. Below, we have compiled a list of common mistakes that medical service providers and their billing companies must avoid:

Not using the correct CPT codes – the endocrinology procedures are complex and can require multiple codes for a single procedure. It is thus important to make sure that you are using the correct codes for every service provided. For instance, if a procedure requires or involves therapeutic or diagnostic services, you must use separate codes.
Ignoring modifiers, these are an important part of endocrinology medical billing, as they offer additional information regarding a provided service. For instance, the modifiers can tell payers whether the service relates to an acute or chronic condition or to a professional consultation.
Late claim filing – On-time claim filing of medical claims is essential, and it is also important to ensure that all claims are filed within the specified time limits set by payers. Late filings often lead to delayed or denied reimbursements.
Not having or preparing the necessary documentation before filing the claim. Incomplete documentation leads to denials and delays in reimbursements. It is important to make sure that you have the complete information, including the diagnosis codes, payment details, and medical records – all before submitting a claim.
Not following up on claim denials or delayed claims. If a claim does not get paid in full or gets denied, it is important to follow up with the payer to find out what you need to get for getting your claim approved.

Conclusion

These are important tips and pitfalls to avoid when receiving timely and complete reimbursements. Endocrinologists find denials in the endocrinology billing complex. Therefore, it makes sense to outsource healthcare billing services to a reputable third-party medical billing company like Physicians Revenue Group, INC.