A good denial management process is not simply about working on denials, it is about systematically gathering the data required to eliminate denials. Working on denials is like pumping water from your basement when a pipe bursts. Denial management is about fixing the pipe so you no longer need to pump water from the basement.
Over the years we have learnt that three elements are typically missing from a practice or medical Provider's denial management process: data, filtering/sorting methodologies, and feedback to systematically correct errors. Most practices & practice management systems do not properly track denials - at least not in the form in which they are typically used (i.e., they may have the capability, but only if properly implemented and used). The practice management systems that do track denials typically overwhelm the practice with data that is difficult to utilize for high level denial management. Finally, even if the data is captured and can be properly utilized, most practices do not have a systematic way to get the information back into the billing process in a manner that prevents the denials from occurring again in the future.
Below is a list of few common denials:
· Claim denied for Missing / Additional information
· Claim denied as Duplicate
· Claim denied for Prior-Authorization / Referral
· Claim denied as Inclusive
· Claim denied as not medically necessary / Pended for medical notes
· Claim denied as non covered service
· Claim denied for eligibility
· Claim denied for late filing
· Claim denied as CPT – Dx mismatch
Here’s a proven methodologies I would like to suggest.
Focus on key fundamentals like Prevention, Analysis and Tracking.
Prevention:
Prevention focuses on actions that can be taken upstream in the patient encounter to prevent denials from occurring in the first place. Prevention can be introduced anywhere in the patient encounter such as: Pre-admit/Pre-registration, Scheduling, Admit/Registration and Billing.
Analysis:
The process of analyzing and aggregating similar denials is strategic in denial management. Analysis and segregation is a forerunner to follow-up process and hence it is a fundamental step in denial management.
Tracking and Trend Management:
Besides keeping a track of the denial trend from payers, you need to actively monitor the payment patterns from various payers and set-up a mechanism to alert when a deviation from the normal trend is seen. This is important in understanding the causes of claim denials and enhancing long-term efficiency and drastically reducing lost revenue.
