A Guide for Comprehensive ” DENIAL MANAGEMENT”

Denial Management, in simple words, is a strategic process that resolves any issues which might cause claim denials. Both rejected claims and denied claims have the potential to be a huge issue for healthcare organizations. Denial management is considered one of the most complicated yet vital parts of the revenue cycle management process. Seeking professional help from a medical billing company with the right tools is considered the most convenient solution here.
As denied and rejected claims have a direct impact on the revenue cycle, it is important to get it right. It is advisable to employ a system monitoring the denials and what causes them. This is one of the most important steps to take into consideration before you try and look for solutions. So here is a comprehensive guide for the Denial management process.

There are two types of Denials

1. Hard Denial – A hard denial is permanent, and cannot be corrected or reversed. Hence the revenue over which is considered to be lost.
2. Soft Denial – A soft denial is temporary, and is payable if the necessary information is added or rectified.

Claim Denial can be a result of many issues.

Here are the top five to keep an eye out for:

1. Duplicate Claims – This situation arises when a claim is submitted for a single encounter on the same day for the same patient by the same provider for the same service team.
2. Incorrect or Missing Information – This covers anything from a missing field or blank field to coding errors.
3. Prior Authorization – Before service is performed if prior authorization is not being taken then the claim can be denied.
4. Benefit Coordination – Patients who are covered by more than one health plan can lead to delays or denials of claims. This can be avoided if the patient’s benefits are coordinated.
5. Network Provider – If the services are provided by an out-of-network provider can lead to the payer denying to pay the claim or a part of it.
6. Deadline Exceeded – When the payer’s required days of service are exceeded it can lead to delays in claims.

Once you have correctly located the causes for denials, here comes a tougher task. Denial management and making sure that it does not occur frequently is a meticulous procedure.

Here are a few things to keep in mind to make this process easier:

1. Common Reasons – Denials or delays in claims can occur due to various reasons. It primarily depends on the type of healthcare organization and the scale on which they function. If there are any repetitive errors occurring then specific changes along those lines need to be made.
2. Quick Assessment and Action – In case any denials take place or if there are any delays then it is important to follow up and get them corrected. The preferred time limit for this is within a week.
3. Clear Delegation of Jobs – Managing the denials procedure is a tedious process. It consists of a lot of steps and they need to be error-free for a seamless workflow. If the work is delegated amongst different departments or outsourced to medical billing agency or a medical billing company can assure error-free and hassle-free work.
4. Establish A Work Model – In any healthcare organization denials are an integral part of the revenue cycle. An effective work model in place can help you handle this issue in a much better manner.

Keep The Process Organized – An organized denial management process can facilitate solutions to resolve any delays or denials in claims. Denied or delayed claims can lead to a reduction in revenue and some grave administrative issues.

Financial stability is vital for any healthcare organization. A sustainable Denial Management process can help streamline the process while weeding out any causes leading to denial or delays. A simple solution could be to outsource medical billing services to a medical billing agency.

We, at ICS, provide the best-in-market medical billing services equipped with an experienced and skilled team to turn denials into revenue.

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