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Denial Management Process and Outsourcing

04Jun

Denial Management Process and Outsourcing

Read Time: 3 minutes

It takes a lot of time and effort to research and resubmit denied claims. Moreover, the longer one waits to resubmit denied claims, the more likely it is that they will not recover the whole amount from the insurance payer; or worse, they will not get reimbursed at all. Thus, a claim denial management approach is essential for swiftly identifying, resolving, recovering, and preventing denied claims.

Types of Denials

To better understand why claims get denied, here are the most common types of denials:

Missing information

You can trigger a denial by leaving just one necessary field blank on a claim form. Sixty-one percent of initial medical billing denials and forty-two percent of denial write-offs are due to demographic and technical problems, such as a missing modifier, an incorrect plan code, or the absences of a Social Security number.

Duplicate Claim or Service

Duplicates or claims resubmitted for the same encounter on the same date by the same provider, for the same beneficiary, and the same service items are among the leading causes of medical billing claim rejection, accounting for up to 32% of claims.

Service Already Adjudicated

This error emerges when benefits for one service get included in a payment or allowance for another treatment or already adjudicated procedure.

Not Covered by Payer

Checking data in the insurance eligibility response or calling the insurer before delivering services might help minimize medical billing denials for operations not covered under the patients’ existing insurance programs.

Limit for Filing Expired

Medical claims must get submitted within a certain number of days of service, according to most payers. This timeframe covers the time it takes to revise denials, as well as whether you automated the review (e.g., a system checking for faulty coding or other errors) or complex (e.g., licensed medical experts assessing if the treatment was covered and was reasonable and required).

Correction of inpatient medical coding errors, which accounted for 81 percent of complex claim denials in the fourth quarter of 2015, can result in delays that cause medical bills to be late. When medical claims are approaching their deadline, workflow procedures should warn personnel.

Denial Tracking and Management

Losing track of refused claims might become a big problem in the future since they tend to accumulate over time. It becomes complicated to keep track of denied claims if there is no systematic structure in place. However, new tools and technologies assist hospitals in managing and monitoring denials that need to get addressed.

Preventative Denial Maintenance

Staying on top of the denial management process’ development and success are critical since it allows organizations to understand which aspects are succeeding and which ones require improvement. When it comes to underpaid claims, you must document all wins and losses. Ultimately, the goal is to use existing data to increase the efficiency of an organization’s denial management approach.

Strategies to Work Denials

Establishing an efficient denial management procedure also requires identifying the sorts of denials most typical in an organization. Each kind of denial may appear to be a minor issue at first, but when firms track and analyze these tendencies, serious difficulties within their businesses may emerge.

Following the categorization of denial grounds, you can establish a tracking and reporting method for an implementation to determine the following pertinent information:

  • Top denial categories affecting the organization
  • Top payers affecting the organization in terms of claims dollars denied
  • Top departments or service areas affected by denied claims

Why Outsourcing is the Most Cost-Effective Strategy

For cross-departmental teams in an organization, outsourcing speeds up the repair and re-submission of denied claims. An intelligent workflow engine uses client-specific logic to efficiently distribute denied claims that need to be resubmitted to the appropriate departments and team members while also keeping track of actions undertaken for every claim.

Analyzing the various reasons for claim rejection can help you improve long-term efficiency and save money. Organizations can easily assess remittance advice, revealing prospects for effective denial avoidance as outsourcing service providers have incredibly effective, internet-based denial management in medical billing.

Moreover, outsourcing opens a wealth of advantages, including:

  • Provide a single, on-demand view for all users to manage all aspects of claim denials and re-submissions.
  • Manage claims denials from all payers.
  • Reduce first denial rates to less than 4%, which is the industry standard.
  • Provide key trending reports to assess the impact of process improvements.
  • Ensure the meeting of all HIPAA technological security and privacy requirements.
  • Provide high-quality services at a low cost with a short turnaround time.
  • Access to world-class talent.

Conclusion

When organizations outsource denials management, they gain access to a pool of skilled experts with substantial knowledge and experience. Expert areas include everything from claim submission and appeals and standard coding regulations to NCD and LCD regulations. This need for experts prevents denials and guides individuals in avoiding similar events in the future.

The Outsourcing Denial Management Process ultimately allows organizations to reduce costs without compromising quality service delivery among their stakeholders.

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    IDS Commander iTech2021

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