How to Create an Effective Denial Management Strategy

Medical claims are an important aspect of your practice’s revenue. When claims are refused, it can be a significant source of financial loss. Denied claims not only increase days of the revenue cycle, disrupting cash flow, but they can also cost you money if not resolved quickly. The cost of processing each refused claim further adds to the strain. Are you experiencing high denials, and looking for a sound strategy to manage these denials? It is important you understand why your claims are being denied, based on which you can devise a strategy to reduce further denials and keep your practice from losing revenue.

Types of Denials

• Soft Denials – A soft denial is only meant to be temporary. If the claim is amended and/or further information is added, it may be paid.
• Hard Denials – It is irreversible. It is revenue that has been lost since it cannot be rectified or restored.

Reasons Why Claims Get Denied

Identifying the cause for the denial is the very first step in an effective denial management strategy. When evaluated claims are sent unpaid, the insurer will usually explain why on the accompanying payment explanation. It’s vital to remember that the majority of people are unaware of the insurance denial process. It is your front office staff’s responsibility to emphasise the need of precise documentation and insurance information.

1. Service previously settled
2. Service unqualified under a healthcare plan
3. Missed deadline
4. Incorrect/missing information
5. Duplicate claims

The following pointers form the basis for an effective denial management strategy

1. Identify – Find and fix the problems that lead to claims being denied by insurers.
2. Manage – Categorize denials according to their reason, source, cause, and other distinctive characteristics.
3. Monitor – Keep track of denials, audit employees’ efforts, and give the tools, technology, and resources needed to get the job done.
4. Prevent – Work with patients, recommending physicians, and others to appeal and overturn unjustified denials.

Read on to know more about how to go about developing an effective denial management strategy.

Re-submit Claims in the Stipulated Period

Follow your rejection management guide, evaluate the insurer’s associated denial communication, and double-check your internal documents. If necessary, contact the patient. Remember that most insurers have time constraints on resubmitting claims; the last thing you want is to be denied reimbursement because of a late submission.

Examine the Denials

The easiest method to deal with claim denial is to prevent it from occurring in the first place. According to industry sources, the typical denial rate for practices is between 7 and 10%, whereas there should be no more than 4% and no more than 2%. Preventive denial assessment is a root cause analysis of all denials received with the goal of lowering the denial rate in the future. Here are a few things you may to want to analyze –

1. What was the source of the denial? Was it a billing error, a coding issue, patient eligibility, the wrong payer was invoiced, or anything else?
2. Is it possible that this denial might have been avoided? The solution to this question will astound you.
3. What could have been done to prevent the denial? Review your eligibility verification procedure to see if it needs to be fine-tuned if it was an eligibility issue.
4. Perform an 80:20 analysis of your denials to determine which issues are the most bothersome and how they might be rectified.
5. Don’t try to change all of your processes at once; taking it one step at a time will yield better outcomes.

Watch For Trends and Patterns

Denials frequently share at least a few common characteristics. Regular analysis aids in determining these trends and identifying causes, allowing you to better plan to fend off income threats.

Organize the Process

The denial management procedure should begin as soon as a denial is discovered. This entails the steps below.

1. Directly route denials to the affected individual’s work list. A coding error, for example, must be reported immediately to the coder.
2. Sort the assignments on the denial work list by cause, time, and cash amount
3. Remember to act quickly to avoid automatic re-billing and to strengthen your case.
4. Create a denial management manual for your workers and create a uniform methodology for each major type of denial.

Denial management is a continuous effort for all healthcare facilities, and it takes up a lot of staff time. You can lower your denied claims by offshoring your denial management process to a revenue cycle management business. Info Hub Consultancy Services (ICS) provides custom-tailored systems and reporting tools for each client. To help you enhance your bottom line, we offer the full range of revenue cycle management services.

We work with you at ICS, an offshore medical billing firm, to reduce denials and underpayments, manage claims, improve patient eligibility verification and payment collections, and reduce compliance concerns and risk. Contact us to improve the efficiency of your daily revenue cycle and business processes.

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