Denial Management: A Unique theory in Billing Industry

Where does misinformation or wrong information in your claims take you to? Any guess? Yes, denials! Denials act as your enemy by blocking most of the revenue and sometimes bringing down your business. Okay, then how well are you managing your denials? Is denial management causing much trouble due to expensive training mentors or trained experts to make the business clearer? Why don’t you switch to outsourcing?

Well, keeping the debate aside, denials are widespread and have turned out to be a never-ending issue in the medical billing industry. Just like the tax and mortgage applications, claims require an ultimate level of specific information to acquire complete denial management, saving the business from loss. Healthcare organizations often risk decreasing cash flow and productivity without a strong denial management program.

This article provides information about how you can build a robust denial management plan to keep your business running.

What is interim Denial Management?

  • Sometimes when the entire healthcare system is confronted with too many claim denials, beyond the management capabilities of the in-house billing department, an interim denial management team is outsourced for support.
  • It continues for a short period of time or can prolong for 3 months, 6 months, 9 months or 12 months, depending on the healthcare organization’s needs.
  • An interim denial management team will also be ready to support health facilities when new systems are in the process of being installed.

How to optimize the denial management process?

  • When denials are not correctly optimized, it affects your revenue cycle and makes it more challenging to move forward.
  • Healthcare professionals and organizations will have to go through a lot of red tapes when dealing with insurance companies.
  • Before they complete a procedure, insurance companies can deny the claims for any reason that matters, whether it’s technicality or any other issue.
  • So, it’s essential to minimize denials and submit clean as well as quickly processed claims.
  • Denial management is considered to be very essential for healthcare companies. Otherwise, you will have to wait longer for your revenue reimbursements.
  • It also consumes additional costs for cleaning and resubmitting the claims.

Cost of Denial Management

  • Without a proper denial management system, your trained staff must make swift through endless codes to find the correct ones.
  • In case they make any single mistake, insurance companies will deny your claims with endless reasons from their side.
  • While we know they should approve the work, insurance companies look for any excuse possible to deny a claim.
  • Once the claim is denied, then it is the healthcare professional’s responsibility to once again go through the claim, find what’s wrong, and fix it.
  • It consumes a lot of time and money, which is not possible for most of them.
  • So, it’s very essential to have not only efficient denial management but also clean first pass claims.

The Fate of Denied Claims

  • Insurance companies well know the busy schedule of healthcare professionals and hospital billing departments.
  • They will have very little time to process the claims and reprocess the denials.
  • This phenomenon decreases revenue because many of them don’t process denied claims.
  • Instead, they get passed on to the patient. It almost forces them to deal with the insurance company. It also brings a loss of revenue to several healthcare companies to begin a prevention-focused claim denial strategy.
  • Denial management in the healthcare process also includes developing automated processes and analyzing denial reasons. By examining these issues, you can build your revenue stream.

Analyzing Claim Denial Reasons

  • One of the most significant assets in denial management in medical billing is having a better understanding of how they occur in the first place.
  • The most common causes of claim denials include missing information, incorrect patient demographics, and technical errors.
  • Almost 90% of claims can be avoided by analyzing the reason for the denials.
  • Human errors are inevitable, but the bulk of these issues can be avoided. It requires better examination by the technicians.
  • Programming that provides automatic filling of information also helps to avoid maximum denials.
  • Duplicate claim submission is another issue, and insurance companies reject and deny these duplicate claims without a second thought.
  • One of the best ways to stop submitting duplicates is the use of programming to keep track of claims.
  • Most of the time, insurance companies decide they don’t cover the services offered by the hospital or provider’s office.
  • There are many policies that do not cover certain claims which the patient and the provider might not be aware of.
  • Insurance claims also have an expiry date. If the billing department doesn’t get the claims out promptly, then the insurance company denies the claim.
  • There are certain programs to remind about insurance claims. A key to decreasing such situations is to have the claims corrected before sending them.
  • They wait until they get the denial from the insurance carrier before examining the claim.
  • Checks and balances can keep such types of common issues from happening if trained staff examines the claims before being sent.
  • In fact, they track the claim denial rate and set goals to decrease it.

Accurate information is vital from the beginning.

  • Most of the claim denials are caused because of inaccurate information. This is part of the front-end revenue cycle management and your denial management.
  • Healthcare professionals must gain information ahead of time and input them into the billing system.
  • If the billing department doesn’t access the patients, they don’t see the patients get the information, so it is up to the primary office staff.
  • When the insurance company denies the claim because the service isn’t covered, hospital or healthcare professional’s staff can check to see if they cover the procedures ahead of time before doing them.
  • Making sure the claim is correct and covered ahead of submission is good not only for the healthcare provider but also for the patient, as he/she need not pay out-of-pocket charges.

Automation makes Denial Management more efficient.

  • It’s important to understand that people are fallible and can improve denial management services.
  • But, at the same time, no matter how well they try, they are always going to claim that they slip through the cracks.
  • This is where automation can help. Many healthcare providers still use manual claim denial management, but automation can help process payer rules and codes faster and more efficiently.
  • Automation also utilizes analytics so you can optimize the various denial management strategies.
  • Analytics also includes interactive reports and other data that can help set benchmarks for claim denials and improve overall strategies.

Denial management certainly is a unique process to handle. But if directed well, it can shower your business with profits. No matter what happens, accurate claims in denial management are best for your practice.

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