As soon as we talk about medical billing, there is one aspect – ‘denials’, that can’t be ignored. The hurdles faced by a healthcare practice in the entire denial management process are huge and need expertise. If the undivided attention is not given, time, effort, and money spent resubmitting claims can create a mess, which can damage the entire revenue cycle.
That’s the reason why your healthcare facility requires a strong & effective denial management process for its progress.
This blog is your guide to the essential steps or strategies that you need to tackle the denied medical claims. Denial management can be understood as a strategic approach to identifying and resolving the problems that contribute to claim denials.
Before discussing the strategies, we will figure out how does denial management works, different scenarios of claim denials, and then we will move forward to the important steps to save you from the denials.
What is Denial & Denial Management?
In the healthcare world, a denial refers to a situation when there is a refusal by an insurance company in respect to the medical claim submitted. It creates an obstacle in the care of patients and results in revenue loss for healthcare providers.
Denial Management in a medical billing process means the process of identifying and solving issues that contribute to medical claim denials.
It includes the management of already occurred denials and prevention in future to strengthen the cash flow.
An effective denial management strategy is the one where the provider has a solution to issues like coding errors. There must be a constant effort to strengthen a better understanding between healthcare providers and insurance payers.
How Denial Management Process Work?
In every healthcare practice, where a strong denial management strategy exists, they follow an IMMP process. It stands for Identify, Manage, Monitor, and Prevent. This process assists healthcare facilities to handle denials in a systematic manner.
Let’s breakdown the process:
Identify
Identifying the specific reason for claim denial is the very first step in the denial management process. Claim adjustment reason codes (CARC) are provided to you by the payers. The main task is to interpret the payer’s feedback and identify the actual reason for denial.
This activity can be time-consuming. However, if you have an experienced team of professionals like Unify Healthcare Services, you can have your medical billing process sorted.
Manage
As soon as the denial is identified, you move forward to appeal the denial and get the claim paid by the insurer. To get this, you have to take the following steps:
Direct routing of denials
Every coding denial must be routed to the provider. This helps in a quick action for denial.
Properly Sort the Work
You can sort out the work by getting a team of professionals to sort the denial management process for you. This will make your process more efficient than it might be when you are handling it yourself.
Create a Checklist:
You can make the process more systematic and error-free when you prepare a checklist of what to do and what not to do. This is quite helpful to avoid common mistakes that might lead to denials and make you stagnant.
Monitor
When we talk about monitoring claim denials, they should be kept by type, date received, date appealed and disposition. You should be able to evaluate the appeals and the team should have the necessary resources. It is important for completing the job swiftly and efficiently.
Monitoring plays an important role in understanding each denial, determining the time, number, source, and type of denial. This data can identify denial trends and establish a better image with insurers reducing denials in the future.
Prevent
This is the final step after the denial management team has gathered all the relevant data related to the claims. A prevention campaign is very effective to reduce future denials by taking steps that include training of staff and adjusting workflows or revising processes.
Multiple teams play their role in claim denial, that is why training your staff and familiarizing them with claim denial methods is important for reducing errors. They must be aware of the errors that can result into future claim denials in areas like registration, lack of authorization or medical necessity.
Types of Healthcare Claim Denials
There could be hundreds of reasons for claim denials. Below listed are some major reasons for the same.
Missing or Incorrect Patient Information
These errors include the minutest mistakes that could be a simple error in the patient’s date of birth or the date of treatment.
Coding Errors
Incorrect codes such as procedures for infants billed for adult patients can trigger claim denial. This is why accurate medial coding and billing is so important in healthcare.
Missing Payer Deadlines
Filing the claim after the deadline is a major setback for medical practitioners. This will lead to absolute denial of your claim.
Missing Authorization
There are certain procedures that require pre-authorization for medical procedures. This includes various surgeries and treatments that have high risk factors or are expesive. If the pre-authorization is not obtained, the payer will deny the claim for non-authorized procedure.
Dual Coverage Issues
If two forms of health insurance coverage are applied and the injured patient who has both primary insurance and worker’s compensation, the claim process will be complicated, especially when there is a dispute with one or both insurers.
Denial Mangement Strategies
There are a variety of ways in which healthcare organizations can implement denial management strategies to proactively address denials, minimize revenue drops and enhance the overall revenue cycle.
Let's go through some commonly used steps to do so:
Maintain Clinical Documentation Integrity
Accurate clinical documentation is the base of serving a true clinical picture. Healthcare organizations must actively identify and target the areas for improvement in documentation, code specificity, and clinical document integrity.
This approach aims at optimizing the chart quality, enhancing completeness and supporting better patient care.
Regular Staff Training & Education
Regular staff training is important for healthcare organizations. At least the staff involved in the revenue cycle process must be trained to handle the claims precisely. By improving the coding knowledge, documentation processes and understanding of payer policies, the staff can avoid common errors which will increase your revenue cycle.
Analyze Data
Evaluating denial data and generating reports can help you identify the denial trends and measure the effectiveness of denial management strategies. Practitioners can use different data analytics tools, the revenue managers can track denial metrics, identify patterns and make informed decisions for improvement.
Simplify Denial Management with Professionals
Denial management is a continuous process that needs continuous improvement, collaboration, and utilization of technology. Providers must stay vigilant and understand the denial trends while implementing targeted strategies.
Partnering with medical billing professionals is a great way to leave all the hassle. Unify Healthcare services is one such organization that has the perfect expertise for denial management. Our dedicated and trained employees are well-versed with all the billing and coding guidelines required for accurate and precise billing.
The ultimate vision of Unify Healthcare Services is to make billing easy for every healthcare provider. We take the load of documentation and billing from you, so you have all the time to focus solely on improving patient care. Ultimately, this will increase the footfall of your practice which increases your revenue.
