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DENIAL MANAGEMENT: 5 EFFECTIVE APPROACHES TO SHRINK DENIALS

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Claim denials may be nothing unusual in healthcare, but the amount denied actually adds up to a substantial sum in the long run and is a loss of revenue for the practice. Studies have shown that many practices do not appeal to denial as they consider the denial management process expensive compared to the amount they will receive from payors.

This erroneous thinking results in leaving money on the table as statistics show that I in 5 claims is denied. Denial management is, therefore, something that every practice should take seriously.

The quantum of claim denials in a facility can be brought down by following the 5 approaches listed below:

1) Studies show that about 90% of claim denials can be easily prevented. According to the 2013 MGMA health insurer report card, most claims were denied by payors for the following reasons:

  • Missing information and technical errors
  • Duplicate claim submission
  • Service already adjudicated
  • Services not covered by the payor
  • Delay in claim submission

The above reasons show clearly that preventing claims denials starts from the front–office when patient registration starts. Insurance and patient information should be accurate and collected before the patient visit. Front-end staff will need to coordinate with denials management/ medical billing teams to know what patient and insurance data are needed to populate a claim form. There should be no errors in demographic entry and front-end staff should ensure that the patient’s insurance plan must cover services to be rendered.

2) The other causes of denials are revealed by data analytics, which helps map out a denial prevention strategy and appeal process. Data analytics should also determine the root causes of denials by analyzing medical records, coding, charge entry and the billed claim. The root cause should be specific so that the denial does not happen again.

3) A non-negotiable practice should be that the billing team must ensure that claims are submitted within time limits.

It may therefore be easier to focus on submitting clean claims to eliminate denials. And timely submission of claims will lead to higher reimbursement.

4) Payors have different rules regarding the reasons for denials. They also have different ways of communicating the reasons for denials. In the absence of standardization of payor rules and regulations, providers and billing staff must become adept at deciphering these rules.

5) Denial management can become more effective and faster by automating processes rather than doing things manually. Using technology to manage denial management will assist a practice in achieving the following goals:

  •  Establish the root causes of denials
  •  Obtain coding/clinical validation changes
  •  Provide targeted education for the front end staff
  •  Negotiate better payor contract terms
  • Develop strategies for prevention of denials

If your practice’s billing team is finding it difficult to handle denials, talk to us. Bristol Healthcare Services is one of the leading medical billing and coding companies with over 20 years of experience in the healthcare industry. Our front-end and billing teams have been trained to ensure that clean claims are submitted by collecting accurate data about patients and insurance plans. Our denial management strategy, which has been perfected over the years, will bring down your denials rate and increase your revenue.

Talk to an expert to find out how we can assist you.