Denial management is a tactical procedure designed to identify and address issues that result in the rejection of medical claims. But the approach should
also reduce the chance of further denials, ensuring that practices receive payments quickly and have a steady cash flow.
A clean claim is filed without any mistakes or other problems, such as inadequate supporting evidence that prevents prompt payment.
Additionally, it satisfies all the following criteria:
Contains any identifying numbers and properly identifies the healthcare provider, facility, home care provider, or supplier of durable medical equipment who performed the service to check their affiliation status, if necessary.
properly identifies the patient and health plan subscriber
gives the time and location of the service.
Is a claim for covered services made on behalf of an eligible person?
demonstrates, if necessary, the medical necessity and suitability of the services rendered
Contains information necessary to prove that prior authorization was acquired for specific patient care for which it was necessary.
uses a commonly acknowledged method of process or service coding to identify the service that was provided.
includes additional documentation based on services given as logically necessary by the health plan.
A brief or interim denial that might be honored if the practitioner makes the necessary corrections; no appeal is required.
A hard refusal necessitates an appeal since it results in lost or written-off revenue.
A sort of hard denial that can be avoided by a practice, usually as a result of incorrect registration information, erroneous codes, and insurance eligibility issues.
Although this hard denial is a result of failure to pay for a necessary medical procedure, an appeal is still required.
Administrative Denial: A type of soft refusal in which the payer informs the doctor's office in detail of the grounds for the denial; an appeal may be made.
Medical billing denial management includes understanding the distinction between rejected and denied claims. When a claim is processed and
subsequently rejected by a payer, this is known as claim denial. In contrast, a claim is rejected when it is sent to a payer with incomplete or inaccurate data or coding.
Many different billing and coding problems frequently result in claim rejections. An incorrect Medicare or CLIA number, insurer name eligibility, a non-payable service, a missing diagnosis code reference number, a duplicate claim submission, or a diagnosis not coded to the highest level of specificity are a few examples of issues. Two important steps to reduce claim denials and rejections in your practice are to watch out for data entry errors and confirm referrals up front.
The amount of money that physician offices could be losing if they don’t pay enough attention to the denial management process. These
practices not only increase their risk of non-compliance with various regulations, decrease patient satisfaction, and waste time and resources that could be put to better use elsewhere in the practice, but they also fail to recover all the money they are owed or receive it days or months later than is reasonable.
Patient eligibility is most likely the main reason that claims are rejected. This indicates that the service requested is not covered by the insurance plan for which it is being billed. Additional factors include:
inaccurate or missing data
late or duplicate submissions
incorrect or out-of-date ICD-10 or CPT codes
absence of supporting evidence or previous approval
absence of a medical need
mistakes in procedure coding
You can reduce claim denials by following these five simple steps:
code detection with the greatest degree of specificity
Verify insurance eligibility and coverage
Present claims promptly
Keep up with the criteria of the payer.
Throughout the entire procedure, keep track of the claim.
Additionally, by keeping track of all your claims, determining the reasons they are rejected, being aware of each carrier's deadlines and claim submission guidelines, and incorporating patients in the denial procedure, you can prevent and better manage claim denials. By using these suggestions, you may gradually improve your revenue cycle and avoid losing out on money that is due to your practice.