At AT&C Revenue Services, we know only too well how claims denials can become a major obstacle to your center’s financial sustainability. It’s only natural — your center relies on insurers reimbursing medical treatments and surgical expenses. You take the time to document the entire claim process meticulously and submit enough information to the payer to ensure prompt reimbursement. It’s only reasonable that having these claims denied represents a significant source of financial stress for your organization.
Let’s recap: Smooth revenue cycles depend on smooth denial management processes. Interruptions to a center’s cash flow can seriously hamper its operations, even to the point of hindering the ability to continue caring for patients altogether. Denial management is how we preserve a center’s income flow by preventing or minimizing reimbursement delays as much as possible.
Put simply, this is one of the most crucial health billing tasks every center needs to get right.
Understanding the Denial Management Process
It has to begin with optimization. A comprehensive understanding of denial management will always lead to leaner and more efficient claims processes from beginning to end. Here are some of the key steps to achieving that yourself.
Categorizing Denials
Try to identify denied claims and categorize them according to the cause of the denial. Many things can cause insurance companies to deny medical claims, such as coding errors, disputes over the necessity of a procedure, and other factors. You’ll want to sort these different denials into a detailed classification system that lets you find patterns and discover the root problem.
Denial Analysis
Ask yourself: “Why was the claim denied?” It’s possible that the procedure just wasn’t eligible for insurance reimbursement, or maybe only a particular aspect of the procedure is ineligible instead of the whole thing. You’ll want to understand what specifically went wrong to prevent future recurrences and help you file your appeal when the time comes.
Take Steps for Next Time
From the information you gather in denial analysis, you can start making plans for the next procedure and claim. You can adapt your processes to prevent the same issue if a part of the previous procedure wasn’t eligible for reimbursement.
There are a lot of technology suites to help you through this process. Consider using a medical claims processing platform like AT&C Revenue Services to help you track the root causes of denials, find patterns in the patient information data, or even refine your future workflows to prevent future denials.
Denial Prevention Best Practices
Your staff team is your center’s first line of defense in denial management. Just review a few case studies to see how important it is to identify common problems in your claims process. Staff are the ones who document procedures, translate them into code, and actually submit the claims for processing. The processes and workflows they adhere to can have a major — and often unseen — impact. Your job is to make those workflows visible.
Perform regular audits of your claims processes and develop a full understanding of your medical billing workflow. That means speaking to everyone involved, incorporating their feedback into your optimizations, and implementing changes gradually. If there’s a consistent pattern of denials in one specific area of operations, communicate that to your staff and provide the necessary training.
This will demand a proactive approach from you and everyone on your team. You’ll need to stay on top of any recently issued payer guidelines and know their eligibility criteria in advance. If you’re using denial management software, you can integrate these guidelines into your processes to automate your claims filtering and tracking methods.
The Role of Denial Management Software
We realize that claims processing is made even more crucial by how potentially time-consuming it is. It’s a vital part of your operations, but that doesn’t mean you have the time necessary to spend on all the finer points required for accuracy. Denial management software can offer welcome relief through automated claims tracking and categorization tools to help you develop a more robust workflow. It can help you to:
- Quickly identify and isolate repeated problems in your claim workflow.
- Find the root causes of claim denials and communicate the fixes to your denial management team.
- Use in-depth reporting capabilities to conduct high-level trend analysis over designated time intervals.
Denial management software isn’t completely hands-free, but it can free you from mundane processing or input tasks and give you back time for correct data analysis. If you’re looking for more in-depth insight into your claims, denial management software is a must-have. It can even help you submit appeals and speed up the resolution process.
Impact of Payer Relations on Denial Management
Payer Provider Relations/Network Management and providers are the two cornerstones of medical billing. You’ll want to foster a strong working relationship with the other party to reduce the chances of unnecessary claims denials. Miscommunications and misunderstandings are two of the biggest reasons for a claim denial, so work hard to build a healthy relationship and have a communications pipeline ready before you need it.
Payer Provider Relations/Network Management and providers should talk with one another regularly. You can establish a schedule of frequently updating one another on different procedures and guidelines, even when you don’t need claims processing. It’s better to have a good relationship ready to leverage when you require it than to wait for something bad to happen.
The best way to build and continue positive working relationships is to understand one another’s procedures and guidelines. Both parties should commit to quality and efficiency, and they should also be equally interested in collaborating. Such a system in place in advance will pay dividends during the denial management process.
Common Challenges in Denial Management
Claims processing and guidelines can feel like they’re constantly changing, making it difficult to keep up — and not keeping up with guidelines is a recipe for a denied claim. Of course, there are many other issues to be aware of, especially:
- The limited number of staffing resources available to handle claims processing. Denial management software can help with this.
- Inefficient claim data-tracking that creates “blind spots” in your trend analysis. You can’t solve the problem next time unless you understand why claims were rejected.
Your center’s staff can soften these challenges by shoring up internal workflows. Center staff should develop clear and detailed guidelines for claims entry procedures and communicate them to everyone involved. Invest the time and money needed to ensure your team knows the importance of claim accuracy, the methods for achieving it, and the immediate steps to take if you receive a denial.
For instance, automation can help you classify claim denials into their respective categories and assess what might have gone wrong. You can use this data to make course corrections on recurring issues and be more proactive in the future. Incorporating this level of analytics into the workflow is one of the most important things you can do to overcome denial management challenges.
Denial Resolution Strategies
It’s best to take a holistic approach to denial management that tackles the issue from both ends. Some percentage of claim denial is inevitable for any healthcare provider, and a robust appeals management process should be ready to supplement your claims. In effect, a strong denial management system helps your appeals process by:
- Providing an accurate and comprehensive level of documentation for all claims.
- Making claim denial information clearer and more accessible.
- Expediting the appeals process by isolating the root problem and helping you find a fast solution.
Remember, your ability to secure reimbursement depends on your ability to overturn at least a significant proportion of your denials. An appeals management system should run like clockwork, and yours should leverage your existing relationship with the payer to further streamline things.
Precision in documentation, from start to finish, will determine the success of your claims, appeals, and resolution processes. This means precision in cataloging the claim before it’s sent to the payer, classifying the denial, analyzing insights gleaned from it, and filing the right appeal. You’ll want a combination of clear records and software providing an “eagle eye” overview of your claim from its first submission to the final resolution.
Moving Forward
If you’re interested in revamping your revenue cycle, request a consultation with AT&C Revenue Services today.