5 Things to Know About Denial Management
Medical practices are responsible for billing for patient visits and collecting payments from insurance providers. When an insurance provider denies a claim, it can create frustration and undue stress. It also leads to an under-billing situation.
Denial management entails managing, and possibly appealing, claims that an insurance provider has denied. You can then take appropriate steps to rectify the situation.
If your practice has a highly technical specialty, such as medical oncology or radiology, you should utilize denial management principles to maximize reimbursement rates.
Nevertheless, here are five things to know about denial management.
1. Identify the Common Reasons for Denial
When you receive a denial notice, there are several possible reasons why the insurer may deny your claim. These may include inaccurate or inadequate information in your claim, failure to file the claim within a specific time frame, and incorrect coding. You should make a targeted effort to identify the source of the denial to minimize future occurrences.
Go through the denial notification carefully, identifying the source and the reason. Check the account carefully for details, such as the service date, procedure, and diagnosis. After reviewing the information, you will better understand what caused the claim to be denied and how to prevent it. You may even request an explanation from the insurance provider.
2. Communicate with the Insurer
When going through the denial process, determine if anything can be done to address and remedy the situation. Be willing to contact the insurer and discuss the situation and file an appeal if necessary. If you did not supply complete or accurate details, be sure to provide them at this time. The best hospital denial management companies can even help you navigate the process of denials if you need more assistance.
3. Coding Is Key to Avoid Denial
If the reimbursement process is denied because of inaccurate coding, this may require a change in strategy. If your practice uses a coding team, you may want to appeal directly to the medical director or leadership to ensure that changes are made and implemented correctly. Changes to the current system or procedural coding should be communicated with all staff, including physicians and billing personnel.
Your coding team should be well-versed in all-encompassing coding guidelines. They should also be able to communicate any changes to coding policies regularly and make sure that you comply with all new requirements.
4. Develop a Repeatable Work Model
Create a framework that outlines the steps involved in your accounts receivable process. This model could include key decision points and the steps involved in denial management. You will have a standard strategy to address the issue if a denial notice is received.
The process should be as simple as possible for all staff members so that everyone understands what needs to occur next. You want to ensure that everyone is working off the same information so there are no discrepancies or misunderstandings in your accounts receivables system.
5. Small Details Matter
Before sending any claims to the insurance provider for review, you want to submit a quality claim that will pass the initial screening process. As part of your accounts receivables strategy, ensure that each claim is thoroughly reviewed before submission to ensure accuracy and completeness. It is best practice to provide as much information as possible so that any information gaps can be easily explained.
The provider statement should include the claim’s details and a brief explanation as to why it is being submitted. Include any supporting documentation, such as diagnostic test results and discharge summaries. The provider statement should be clear and easy to understand so that the insurance provider can quickly determine if you are requesting appropriate payment for your services.
Conclusion
Implement an effective denial management plan and a strategy in accordance with it to increase your cash flow. Medical billing software and billing services can help you get your claims submitted, recorded, and paid accurately. It takes practice to eliminate denial, but you can limit your chances of an unnecessary denial by taking time to understand the issue and implementing a strategy that will bypass the causes of denials.
