Denial is the ability of the Insurance payer to refuse the payment of a claim for the services rendered to a patient by the Healthcare Provider.  A Clinical denial, however, is based on Coding reacted issues, Medical Necessity, Length of stay and or the level of Care, including other clinically related determinants.

Working on getting these denials paid is a tedious and lengthy process. The clinical denials require an appeal by the Healthcare organization.  According to research, the average cost to rework a claim is $25. Denial rate of a 5% to 10 % is the Industrial average. Maintaining this standard below 5% would be the end goal resulting in the organization maximizing its revenue.

Preventive measures instead of reactive measures should be the need of the hour.

  • Calculate your denial rate- (Total $ of claims / Total $ of claims denied)
  • Educate your staff members with regular training and webinars
  • Identifying Pain points and implement Repeatable Processes
  • Evaluate the success rate of your organization by applying a set standard of Key performance indicators

Tips to Eliminate Denials:

  • Almost 90% of denials are preventable if focused on resubmitting claims by correcting them without errors within the deadline.
  • Find the root cause for the denials so that it can be prevented from happening further.
  • Common types of preventable denials are:
  1. Duplicate Claims
  2. Incorrect information
  3. No Pre-authorization
  4. Eligibility verification
  • Majority of claims can be recovered. However, by automating their revenue cycle management, healthcare professionals can benefit and reduce the claim denials.
  • Minor denials due to misinformation or incorrect modifiers can be prevented easily with recorrections. This can increase revenue flow and productivity.

Regular tracking or follow ups on the claims within specific time limit will be helpful to detect the cause for the denials and avoid them in future.

Last but not least Clinical denials result in a major impact on the growth and financial turnover of a Healthcare Organization. When managing staff training and the frequent changes in payer requirements appear to be a challenge, invest in outsourcing. Finding a partner who upholds the values of your business just the same would be a good start. Denials are not the death of a Practice, taking control and eradicating denials increasing revenue would be the end goal. You can know more about Denials Management here