5 Tips on How to Make Sure Your Medicare Claims Do Not Get Denied

Health is wealth. This is especially true in the United States where healthcare costs are one of the most expensive in the world. More often than not, staggering medical costs drive people into poverty. That is why health insurance programs like Medicare have been established to protect people from taking on such huge financial risks. Medicare is in the exact position — it would like to protect itself from fraudulent claims which could affect its ability to provide coverage to those who are actually eligible. As such, medical reviews were developed to identify and evaluate the validity of Medicare claims.

If you have been in the business of providing home health, hospice, and therapy care for quite some time, you would know that medical reviews are lengthy and grueling. Getting your claims denied are not only resource — depleting but are also a huge burden to your agency’s finances. Just imagine the costs spent on phone calls, additional labor, and investigations when you rework or appeal a denied claim. It is especially frustrating if the reworked claim is under-reimbursed or at worst, re-denied. You not only incurred extra costs, but you also did not recover the initial funds you spent, resulting in a significant impact on your revenues.

Data gathered by CMS shows that the most common mistakes committed by providers when submitting their claims are missing physician signatures, insufficient encounter notes to establish eligibility, documents not meeting medical necessity requirements, and incomplete physician initial certifications and recertifications. All of which can be easily remedied and corrected and frankly, prevented. So, how can you avoid getting your claims denied? Here are some actions that you can take.

  1. Switch to an Electronic Health Record (EHR) system

Human error is the number one cause of claim denials. Healthcare providers have long acknowledged this fact and thus, most have transitioned to adopting an Electronic Health Record (EHR) system. Through automating your operations, specifically the documentation and administrative tasks, you can lessen or even eliminate human errors. With a good and efficient software, you can accurately and completely record the patient’s condition, the services your health staff have provided, and all supporting documentation, thereby eliminating any doubt as to the patients’ eligibility and the necessity of the treatments.

In addition, some software in the market already offers built-in integrations with widely-used databases in the industry (i.e. PECOS, PEPID, and PMIC) which lessens the probability of your staff inputting a wrong diagnostic code or an incorrect drug data. Some also have predictive features which flag and notify staff if there are any missing or incomplete items that may affect the billing and claims submission process. Switching from manual to an EHR system will not only mitigate errors but will also save you time and money in the long run.

2. Stay updated on the latest industry policy changes

The healthcare industry constantly evolves and changes as driven by technological and medical advancements. It only then follows that policies and regulations are updated and revised to align with these changes. Your software might be able to give you information on policy updates but when it comes to understanding how these will affect your agency’s operations, there is no better way than to hear it from the source. On top of subscribing to newsletters and reading online informational write-ups, your team should take advantage of webinars, seminars, info sessions, and conferences that CMS, NGS, HHS, and other regulatory bodies organize. When it comes to billing, ignorance is not bliss. You would have to be aware and informed of the latest Medicare standards to avoid getting your claims denied. When you know which policies are usually interpreted too strictly by Medicare, then you can take the preventive actions to ensure that your claims will not go to the denied pile.

3. Evaluate your current data and identify high error areas

It pays to be proactive and predictive. If you already have an EHR, take advantage of its report capabilities to analyze and identify the areas where you commit the most errors. Regularly measure and assess your current data against standards. Knowing the root-cause for why your claims keep getting denied will help you develop a plan to prevent it from repeatedly happening whether that be through process improvements, training programs, or any other means.

4. Train and engage your staff

This goes back to the point that most mistakes are due to human errors. As such, your staff should be properly and regularly oriented and trained to accurately fill out and complete forms. The devil is always in the details so they should develop keen and consistent attention to even the smallest of the data required in claims submissions. An in depth-understanding of Medicare standards as well as the different types of probes (e.g. TPE) will also help them formulate a better approach on how to respond to these reviews should your agency be subjected to one. Most importantly, a strong culture of communication should be fostered between medical and office staff, paving the way for knowledge sharing and eliminating any errors caused by miscommunication.

5. Stick to deadlines

Probably the most unacceptable mistake when it comes to claim denials is late submissions. Strict adherence to deadlines must always be observed especially when Medicare asks agencies to submit Additional Documentation Requests (ADR) which are to be complied with within 45 days. An efficient EHR system where billing staff can simultaneously work on claims and where you can easily extract and download supporting documentation from, can definitely help manage your timelines.

A proactive approach to the billing and claims submission process is the common factor to all these actions. In this kind of situation, it is best to take advantage of technological solutions that will make your billing practices more efficient and cost-effective. Data Soft Logic (DSL) can help you in this regard with our intelligent and innovative software solutions specifically designed for home health care, hospice care, and therapy care. From patient intake until claims submissions, we will make it easy and convenient for you without you worrying about compliance. To find out how, schedule a demo with us now.

To be updated on the latest industry policy updates, join the webinar, A Meeting with the Medicare Administrative Contractor (MAC): NGS Home Health Updates, on November 11, 2020 to be conducted by Ms. Shelley R. Dailey MSN, BSN, RN, CPHMM, from the National Government Services.


For more details on this webinar, check, like, and follow DSL’s Facebook and LinkedIn pages.




A Software Built by Health Care Professionals with the goal to innovate industry practices improving the overall patient care experience and sustainability of the business. We are trusted by thousands of clinicians, successfully used by over 650 agencies nationwide!

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Enoch Cruz

Enoch Cruz

Enoch is the Co-Founder and CEO of Data Soft Logic Corp. transforming health care organizations in the US for over 16 years now using the power of technology

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