Claims Rejected by Edit- Fixing Denials for Increased Profitability
With the increased use of technology to review claims, there has seemingly been an increase in claims rejected by edit over the past few years. It’s important the RCM experts fully grasp the importance of claims rejections, and how to remedy them to improve time to payment and decrease non-payment issues.
Rejected claims are not claims denials. They have not been entered into the payer’s adjudication system for processing. Rejections must be remedied in order for the claim to be received. Tyles of claims edits include:
Generic Edits, HIPAA Edits, Front End Edits- These edits include all of the basic components required on every claim, regardless of insurance carrier or product line.
All Payer Edits- Edits based off ANSI Standard Implementation Guides, Not Otherwise Classified Edits (NOC), and National Uniform Claim Committee (NUCC) edits.
Medicare Specific Edits: These edits include medical necessity, local coverage determinations by state (LCDS), CMS national coverage determinations (NCDS).
Multiple Payer Edits- These edits can be requested for any payor to identify specific edits that need to be in place at time of claim filing.
Various edits can be put in place in your clearinghouse/RCM system to target and identify claims that may result in a denial.
Smart Edits- Edits that detect claims with potential errors within electronic claims that may result in a claim denial.
Rejections edits tell a story! Though they can be a burdensome task, rejection edits are a helpful provider tool to minimize formal claims denials and improve cash flows. The two main categories of rejection edits are: HIPAA Edits and Smart Edits. HIPAA edits are often referred to as generic or front end edit. Smart Edits are payor specific edits. Edits, when analyzed properly, can be leveraged as a tool within an RCM department to improve cash flows. Analyzing patterns of claims rejected by edit allow an RCM department to identify opportunities to reduce future rejects. This can be done by developing meaningful front-end RCM edits within a practice’s billing system to minimize overall claims denials.
The key to claims edit success is to take swift action. Carefully read the rejection warning and understand what is necessary to remedy the claim. Understand the difference between HIPAA edits and the (4) types of smart edits that currently exist. Analyze rejection data for opportunities to improve your clean claims filings to minimze rejections on future claims. Create your own claim edits on your billing system to capture potential denials before your claim is submitted to the clearinghouse. Analyze the data, create a plan, and get your money faster!
