Our team of experts uses a simple method to track down and collect on accounts receivable by keeping an eye on each claim.

What Is Denial Management In Medical Billing?

Denial management and rejection management are two distinct concepts that often need clarification. Rejected claims refer to claims that have yet to be processed by the payer’s adjudication system due to errors and must be corrected and resubmitted by the billers. On the other hand, denied claims are claims that have been processed by the payer but have been denied payment.
Healthcare organizations should prioritize addressing both rejected and denied claims. The claims rejection management process can help identify and correct issues with the claim. In contrast, denied claims represent potential loss or delayed revenue if the claim is eventually paid after appeals.
Billers must conduct a root-cause analysis to successfully appeal denied claims, address the underlying issues, and file an appeal with the payer. Healthcare organizations must continuously address problems with front-end processes to prevent denials from recurring in the future and maintain financial stability.

What are the most common denials in medical billing?

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Claims may be denied if patient demographics, insurance information, or referral/authorization documentation need to be included or completed. Therefore, ensuring that all necessary details are complete and accurate is crucial.

Assigning incorrect medical codes, like diagnosis (ICD-10) or procedure codes (CPT/HCPCS), can result in denials. This can happen when the codes need to be corrected, do not match, or there needs to be more documentation to support the codes that have been billed.

It may be allowed if there is more proof to show that a medical procedure or service is necessary. To avoid this, thorough documentation is essential to justify why the treatment or service is needed.

Submitting multiple claims for the same service, intentionally or accidentally, can result in denials. Payers usually have regulations and checks to detect and reject repetitive claims.

Every insurance company has a set deadline for submitting claims. If the claim is not offered by the deadline, it may be denied based on the timely filing rules.

Certain insurance plans may require pre-authorization or referrals for specific procedures or specialist visits. Fulfill these requirements or document them correctly to avoid denied claims.

When a patient has multiple insurance policies, it’s important to coordinate benefits properly. You can avoid having claims denied by correctly blending the benefits between the primary and secondary insurance plans.

The claim may be denied if a patient’s insurance coverage has expired or is not qualified for the service billed.

Errors in the billing process, such as inaccurate patient or provider details, mismatched codes, or typos, can result in denials.

Benefits of our

Denial Management Solutions.

Claim Resolution Focus

Our primary focus is on resolving claims rather than simply obtaining status information. We dedicate our efforts to fixing the claims and ensuring a successful resolution.

Claim Status Checking

By enhancing the adoption of web portals, we minimize the effort required to check the status of claims. This automation allows for convenient online access to claim status information.

Workflow Automation

We incorporate web-based systems tailored to each claim status code. These systems prompt insurance companies with relevant questions to address claim issues, improving documentation quality.

Comprehensive Dashboards

We generate multi-variate reports to gain a clear understanding of accounts receivable (A/R). These reports provide valuable insights, enabling us to focus on effective resolution strategies.

A/R Reduction

Our benefits include a minimum 20% reduction in A/R days and an approximately 5-7% increase in collections. By optimizing these areas, we ensure improved financial outcomes.

Regulatory Compliance

Our services help healthcare organizations comply with evolving healthcare regulations and payer requirements by staying up-to-date with coding guidelines and billing regulations.