Denials tend to evoke frustration and a loss of motivation to work. Hence it is essential that strategies are designed to manage the Denial Management process effectively and use it to improve the revenues of a medical practice. Claim denial management process is one of the most vital aspects of a revenue cycle management process. In fact denials are a staggering 5-10% of hospital claims wherein the number should be below 5% to improve medical reimbursements.

One of the chief reasons for high claim denials is the usage of a manual claim denial management process in medical billing. Further many healthcare facilities do not have a manual or electronic claim denial management process in place. Around 30% of claims are denied when submitted the first time; moreover, around 60% of these are not re-submitted due to busy schedules of medical professionals. As of 2017, Medicare denied 5% of claims.

Here Are Some Best Practices To Be Followed For Handling Claim Denial Management:

1. Identification:

   The first step is to identify the causes of denials – incorrect data/registration entry, charge entry error, duplication, no medical necessity, termination of insurance coverage, pre-authorization errors, bundled/non covered procedures/services, invalid codes etc. For understanding the reasons, it is imperative that claim submissions are monitored regularly, and payments checked- if the practice is getting underpaid or overpaid.

2. Technology:

   Data in EHRs can be authenticated with patient eligibility in real time and verification of insurance coverage well before hand. An EHR system allows the healthcare facility to track the claim denial reason, connect with the patient on the same, and, file and appeal for the same in medical billing.

3. Claims Denial Log:

   It is vital to maintain an electronic log which must contain the insurance company’s documentation, details of the codes denied, service date, amount, individual claim numbers, and if the denial has been appealed or resubmitted again. It is also important to know the most common denials and trends, while streamlining the denial management process so that no denial claims are over looked/not addressed.

4. Expertise:

   It is advised to have a single biller handling all the claims, denials and follow ups of a single insurance carrier. This creates ease of working along with matters being handled in an appropriate manner, as every insurance carrier has their own rules and regulations to be followed.

5. Progress:

   It is vital to file the appeal within a week of the denial received, or the stipulated time given by the insurance carrier. For this, claims must be observed and tracked regularly. It is vital to know the areas working/not working/need improvement by using the available data.

6. Components:

   Other components of a denial management system must include generating reports and identifying new rules for your medical billing. Automatic alerts must be sent to people in-charge of denied claims and submissions. Further scaling of software along with its integration must be made possible as per the healthcare’s requirements.

7. Real Time Analytics:

   This must be used for real-time reporting. Through analytics dashboards, interactive reports, and claims level data, denial and claim management processes can be streamlined and the potential issues can be corrected before submission of claims.

It is best to prevent denials from occurring while analyzing the trends at each stage so that they are not repeated in future. Outsourcing denial management services can ensure accurate reimbursements as the outsourcing medical billing agency contacts the patients; determine the coverage in advance while securing an approval before the treatment is rendered. This enhances efficiency while reducing denials and ultimately reduces any loss in revenues. As causes are identified and addressed, revenues flow in and business improvements are identified. Implementing best practices can ensure maximization of revenues.

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