How to Improve Denial Management in Healthcare

Article Highlights

  • Denial management in healthcare can be overwhelming for medical practices.
  • Understand the root causes of denials and work to improve processes.
  • Work with PMB to support denial management to optimize revenue collections.

Denial of service is never an ideal scenario in a health care setting. Advanced scheduling, prompt service, desirable patient outcomes, and seamless claim management services are what most health organizations and facilities strive for. Yet, sometimes the processes are not as straightforward as we would like them to be. This can lead to prolonged claim processing and denials.

To remain profitable and to continue serving clients in a beneficial manner, prompt claim processing and minimal denials are key to the success of health systems. But there is A LOT of work that goes into keeping up with a growing pile of denials and, at times, managing these attributes may simply be too much. That is where Precision Medical Billing steps in to support denial management in healthcare.

Understanding the Root Causes of Denials

To begin resolving a high number of medical claim denials, you must first understand what is causing this issue in the first place. Sometimes it may be rather straightforward, and other times you may have to do a little digging to discern why denied claims continue to affect your practice’s activity.

Inevitably, there are several root causes that undeniably contribute to current and future denials. Addressing and resolving these issues is key to improving claims denial management within your health care setting.

– One of the top reasons for claim denials is a lack of information or improper information. These are typical occurrences in busy healthcare organizations. Double-checking information that is put into your management system can aid in reducing denials that stem from these errors. Outsourcing claims processing to an outside entity, such as PMB, can also be a solution.

– Other times, denied claims are the result of non-covered charges. These may be from procedures that are not covered under a patient’s plan or from incorrect procedure codes. Nonetheless, these claims will be denied if the plan does not warrant coverage for them. This is why insurance benefits verification is so very important and should be done at the time of scheduling and pre-care.

Seeking prior benefit verification or reaching out to health insurance entities before a patient’s appointment can provide information on claims processing that may arise before a claim is denied.

– Another one of the most common root causes of denials is a lack of pre-certification or pre-authorization. Just because a procedure is a covered benefit doesn’t mean you can just perform the service if needed.

Some procedures still need to be given a go-ahead by the insurance company. Knowing what procedures require this on certain types of health plans is beneficial in obtaining timely and proper payment from insurance companies and patients.

Improve Processes for Denial Management in Healthcare

Just because a medical practice is experiencing issues with a large number of patient claim denials does not mean there is not any hope. In fact, PMB can assist in resolving many factors that contribute to health claim denials.

The key to proper management of denials is to understand your organization’s blind spots so that you can begin to correct these shortcomings. Aside from seeking proper verifications and prior authorizations, actively monitoring claim filings is a good place to begin. This will allow staff to respond to any concerns from the insurance company prior to outright denial.

Addressing denial management in a healthcare setting can also benefit from a review of the reasons for claim denial. If you notice certain claims are getting denied for the same reason continuously, your organization can benefit from a process revision. Sometimes, even a small tweak in how your staff manages outgoing claims can make all the difference.

For example, if you know a certain insurance company prefers a particular coding technique, use that at the first claim filing to increase the likelihood of acceptance. Our professionals at PMB understand the ins and outs of health insurance billing and can help navigate these difficult waters.

Timely resolution of health care claim denials is also critical. Improving the denial management process often consists of timely interactions with healthcare companies. By monitoring claims on a daily basis, issues can be resolved more quickly. This creates more efficiency in your healthcare organization’s revenue cycle management to optimize cash flow.

How Coordinated Denial Management Can Benefit You

Seeking out required authorizations for patient procedures beforehand, double-checking for errors, ensuring plan coverage, and catering to the needs of specific insurance companies are important steps to create more efficiencies in claims processing and to help reduce denials.

Your staff members then have more time to focus on other critical tasks at hand instead of trying to manage a mountain of paperwork from denied claims. 

PMB understands how time-consuming claim denial management can be. That is why we want to help you streamline your processes. By providing reliable billing and coding services in medical settings, PMB helps increase the rate of claim acceptance for your practice.

In fact, PMB has a company claims acceptance rate of 98%. Let us apply our expertise to help increase your cash flow.

Ready to optimize cash flow in your organization? Contact us today to discuss your specific challenges. We have a solution for medical billing, coding, and revenue cycle management that will fit your needs!