California Physicians Worried About Increasing Denials Turn to MBC for Assistance


Denial rates of California’s biggest payers being as high as PacifiCare — 39.6 percent, Cigna — 32.7 percent, HealthNet — 30 percent, Kaiser Permanente — 28.3 percent, Blue Cross — 27.9 percent, Aetna — 6.4 percent, the Denial rates in California are witnessed to be on an all time high, as reported by California Department of Managed Care. From 2002 through June 30, 2009, the six insurers rejected 45.7 million claims — 22 percent of all claims. 

Contradicting general expectation, the rate of denial by private players is lesser than the Government program, the Medicare program since its inception acknowledged the existence of regional variations in medical practice reimbursements and has sought to accommodate these differences in adjudicating claims but California denial rates seem to be standing out.
 
But according to the AMA‘s National Health Insurer Report Card annual, Medicare denied medical claims at nearly double the average for private insurers: Medicare denied 6.85% of claims. The highest private insurance denier across US was Aetna @ 6.8%, followed by Anthem Blue Cross @ 3.44, with an average denial rate of medical claims by private insurers of 3.88%

Even after these denial ratios dropped one year, the observed trend suggested that the denial rates are manipulated to suit the requirement of that fiscal year. Our Medical Billing and Coding specialists suggest the use of industry best practices to accomplish steady income and reduction in denial rates

Medical Billers and coders from our consortium having a base in California have had a close look at the trends in denial management in the past decade, they have managed to discover a pattern or particular reasons for every payer in the state denying claims. 

These billers discovered that Carriers differed in how they treated incomplete claims, if information required by the payer to process the claim was missing, the carrier could:

  1. Return the claim to the provider, this action of the carrier is like the claim had never been submitted
  2. “Develop” the claim (delay adjudication and try to obtain the required information by contacting the provider)
  3. Deny the claim, the provider then had to resubmit the claim or go through the appeal process to obtain payment for this service

Denial Management is getting tougher even for specialists as the Carriers even differed in how they interpreted certain national coverage, most specialists are confused as the charge raised by them for different carriers is being treated differently.

A decade long study has also been brought out by expert billers and coders from Medicalbillersandcoders.com, this study reveals resolutions and check list formats of how to bill for the top five deniers in the state of California in order to have maximum payout for physicians and minimum denials.

Some of the specialist practices even noticed a denial of 7% of claims submitted in the current fiscal year, with the reimbursements freezing physicians groups are definitely looking to manage profitability better. They are seriously looking for specialists who can handle their denials specifically. Medicalbillersandcoders.com members in California are highly specialized in working denials and depending upon the age of the claims and reasons of denial can even provide assurance of collections.

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