The threat of claim denials constantly looms over NEMT providers. They face claim denials or delayed payments due to various reasons. One of the most notable being duplicate claim filing, i.e., submitting the same claim more than once for the same service patient and date. Other common NEMT denial reasons are due to:
- Delayed claim submission
- Incorrect CPT or ICD-10 coding
- Inaccurate or missing documentation
- Issues in eligibility verification
- Change in payor policy
The worst part is, NEMT denials due to any reason can cost you dearly. You can lose valuable revenue, suffer from rising administrative costs, bad debt, the risk of getting affected by compliance issues, and compromised NEMT services.
As a Non-Emergency Medical Transportation (NEMT) provider, you create and submit a claim accurately expecting complete, timely and smooth revenue against it. However, it gets rejected due to any reason causing financial disruption, increased administrative burden and unending frustration for the providers.
Solution?
NEMT providers, their staff or third-party NEMT billing services providers need to take a proactive approach. They need to devise an efficient and pro-active denial management strategy that enhances clean claim rate and eliminates errors and resulting in denials.
By doing so, they ensure less number of denied or delayed claims, a revived cash flow, improved transportation services and better customer experience. However, the tough part is to know the common NEMT claim denial reasons that hurt your revenue generation ability the most.
Want to find out? Stay put!
Common Reasons for NEMT Claim Denials
According to an estimate, close to 70% of NEMT claims denials can be avoided owing to careful claim creation, accurate documentation, precise coding, timely eligibility verification and submission based on payor guidelines.
Many Non-Emergency Medical Transportation service providers face rejections due to small preventable mistakes which end up disrupting their revenue collection and increasing administrative burden. Want to know about the common NEMT claim denial reasons and how you can avoid them? Here are the most prevalent NEMT claim reasons.
- Missing or Incorrect Information
- Incorrect Billing Codes
- Duplicate Claims
- Lack of Proof of Medical Necessity
- Late Claim Submissions
Let’s now go into the detail of these denial reasons and tell you preventive measures to follow before submission to grab complete and timely revenue.
Missing or Incorrect Information
Inaccurate or not filling complete details accounts for 49% of NEMT denied claims. Healthcare providers, their assisting staff or third-party medical billing companies don’t pay full attention to all details and end up missing out on valuable revenue and increasing their workload. Some common errors or incorrect information in the claims that demands utmost care during filing are:
- Incorrect trip details
- Mileage or exact kilometers
- Inaccurate insurance or patient details
- Pickup or drop off times
- Exact NEMT billing codes
- Incomplete service records, i.e., missing wheelchair accessibility information
How to Fix Missing or Incorrect Information?
A thorough and timely pre-submission checkup process is the difference between claims accepted in the first attempt Vs. denied claims. Regular auditing and communication with the payors also makes a huge difference.
Some other differential factors to improve your documentation process and nullify the documentation errors are:
- Integrating automated systems to verify patient information
- Using modern software to log trip times and mileage
- Updating and signing authorization forms
- Educating staff on documentation standards
- A systematic claim review before submission
Incorrect Billing Codes
Selecting the exact NEMT billing code and appending it from a large database of CPT and ICD-10 codes is crucial for high first-pass acceptance rate and a smooth flow in income. While creating NEMT claims, it is easy to make coding related mistakes like placing outdated procedural codes, wrong transport modifiers, mismatched procedure-diagnosis codes etc.
For instance, an NEMT company has provided a stretcher assisted service. Now at the time of filing a claim, if they use a wheelchair transport code instead of the exact stretcher assisted service code, the payor will reject their claim.
How to Fix Coding Errors?
Coding education and availability of required resources to NEMT coders is a must. Some careful steps to avoid incorrect billing codes that are responsible for NEMT claim denials are as follows.
- Incorporate technology like automated code verification systems or latest tools that catch coding errors in real-time.
- Stay updated with industry news and expert guidance. It helps to rectify errors and accelerate payments.
- Invest in educating your coding or claim creation team on how they can use the exact codes and rule out the chances of such mistakes leading to denials.
- Introduce a system of comprehensive claim reviews, before submission, to ensure the code matches the service provided.
- If coding confusion arise, check the website for Centers for Medicare and Medicaid Services (CMS) if coding confusion arise.
- Conduct bi-monthly or monthly audits to analyze denial pattern and spot recurring issues.
Submitting Duplicate Claims
Submitting duplicate claims is one of the main reasons for NEMT claim denials. It happens when the service provider submits multiple claims instead of one. It leads to straightaway denials and stricter policies for such payors leading to affected reimbursements and damaged relationships with the payors.
Experts also suggest that regular instances of duplicate claims within a short span of time means close scrutiny of all future submissions for the provider. On their own end, it leads to increases administrative burden, overhead and delayed payments.
How to Fix Duplicate Claim Submission?
Some practical tips on how to minimize duplicate claim submissions and hence denials include:
- Keeping detailed service records with unique trip identifiers
- Incorporating verification steps prior to submitting claims
- Educating staff on how to prevent duplicate claim submission
- Establishing a clear line of communication with payors with regards to resolving discrepancies
Lack of Proof of Medical Necessity
Another common reason for NEMT denials is lack of medical necessity proof, i.e., the NEMT service provider is unable to show the proof or of medical necessity. This falls in the missing necessary or supporting documentation and may result in claims getting denied, delayed reimbursements and unnecessary obstacles for providers.
To prevent NEMT claim rejection due to lack of necessary medical records, providers must always be equipped with accurate and complete set of documentation. If you’re using manual systems, may be you can try your hand on digital tracking systems as they automate the fetching of important documents. These tools ensure every detail is accessible during and even after the submission process.
Important documents that prove medical necessity
- Physician orders to confirm the medical need for transport
- Trip reports, i.e., mileage, pickup and drop off points to show the services was rendered
- Medical records to show necessity for the service provided
How To Fix Lack Of Medical Necessity Proof?
Make use of latest technology and integrate automated claim scrubbing tools that detect incomplete or missing medical necessity proofs before the submission. This way, there are less risks of denied claims and more chances that you get paid the full amount you deserve.
- Make clear documents about the patient’s condition
- Don’t miss out on specific mobility challenges
- Verify healthcare provider’s orders and medical records
- Ensure compiling complete trip details and include service-related reports
- Take advantage of electronic tools like software to ensure accuracy
Late Claim Submissions
Just like payor submission guidelines, ensuring payor timelines is also important. As an NEMT service provider or a NEMT billing provider company, you cannot compromise of submission dates. Submitting claims late means denials and lost revenue, if you’ve done all the hard work while creating the claim, ensuring the right documentation, appending precise codes etc.
If you don’t meet the submission deadlines, you’re not following the regulations and payor guidelines which means financial disruption and burdening yourself with unnecessary costs. The foremost thing to keep in mind during the NEMT claim preparation process is to stay on top of submission guidelines.
How to Fix Late Claim Submissions
Make a list of the timelines for different payors as different insurance companies may have different time limits. Use a modern software that creates alerts for approaching deadlines. this makes it easy for providers and lowers the risk of late filing.
Apart from automated time limit tracking systems, ensure a claim management protocol that helps you recheck the claim before the final push. Another way of doing it is by maintaining strong relationship with the payor. It will help you resolve pre-authorization issues as well as missed deadlines.
- Ensure periodic and comprehensive audits of your billing workflows
- Ensure documents and documentation systems up-to-date
- Train in-house staff about the legal and financial consequences of late submissions and payor payor specified deadlines
Conclusion
Non-emergency medical transportation has gained tremendous popularity in the last few years across the US. With more and more service providers entering the domain of NEMT, most of them lack the administrative part, i.e., creating clean claims, NEMT claim cleanup process, significance of using the exact CPT and ICD-10 codes, and the consequences of filing duplicate claims.
All these and many more reasons like missing or inaccurate details result in financial disruption and denied or delayed payment. It only leads to financial crunch, frustration and compromised patient care. If you’re handling the claim creation, submission and other core parts of RCM by yourself, you’re risking your business integrity and compromising on the financial integrity.
Why not outsource NEMT billing to an experienced, skilled and a result-oriented NEMT billing company that not only focuses on maximizing your revenue but also works to make you a HIPAA-compliant NEMT service provider. At I-Med Claims, we ensure a smooth and seamless revenue cycle based on your specific needs.
We ensure that all your claims are error-free and attached with all the necessary documentation. With a team of highly professional and industry-certified coders, we ensure to tick every box. We promise to get the claim submitted on time and according to the payor guidelines so that you experience maximized reimbursements, close to none denials and hence no revenue leaks.
