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Denial Management in Medical Billing | PRGMD

Practical strategies for denial management in medical billing are crucial for a practice’s revenue cycle. Denied medical claims lead to loss of revenue, not to mention the additional administrative work for your staff. Managing denials is a complex process requiring attention to detail and niche-based industry knowledge. Effective medical billing services combine best denial management practices and effective communication channels with insurance providers to achieve a high ratio of accepted claims.

Denial Management in Medical Billing and Revenue Cycle Management

Denial management in operations analyzes, investigates, and resolves denied claims from insurance providers. Managing denials is an essential aspect of RCM and medical billing. Revenue cycle management optimizes administrative and clinical processes to boost a healthcare practice’s financial performance and efficiency.

It is important to note that there are several claims processing strategies to control denials. Controlling denials is vital as physicians stand to lose a significant portion of revenue owing to the denial of healthcare claims. The loss of revenue is preventable with a strong strategy for denial management in medical billing. While most denials are recoverable, 60% of the claims are not even resubmitted. This number alone makes denial management an essential aspect of RCM.

Importance of Denial Management in Medical Billing Services

Most medical practices face challenges when it comes to denial management. The sheer amount of effort, time, and resources that go into the resubmission of claims and the loss of revenue adds up significantly by the year’s end. Such situations cause substantial economic damage to healthcare practice. Thus, denial management operations is important for your practice. Let’s look into some of the best practices and strategies for denial management:

Best Strategies for Denial Management in Medical Billing

Medical practices are facing new challenges with the ever-increasing complexity of healthcare billing, reimbursement, and coding requirements. One of these challenges is effectively managing denials. A medical practice must follow the tried and tested best strategies to manage denials effectively. This is in addition to creating winning practices that can align with the overall RCM and billing processes.

Regular Audits

The medical industry is constantly evolving, so what was working before might not work forever. Regular audits on remittance advice reviews, zero-payment claims, insurance, and registration verification quality are essential. Doing so can significantly improve the performance metrics of a healthcare practice.

Ensuring Collaboration

Denial management is not a solo undertaking; thus, your denial management team should not be a single-person effort. Creating a multidisciplinary team of key members from different departments is important. These departments can be patient financial services, registration, nursing, IT, and health information management – all of these combined can help put effective strategies in place. These strategies can thus be put to use for tracking developments and alleviating bottlenecks for the identification of root causes for claim denials. Furthermore, collaboration with payers can also help resolve the denials and ensure the placement of a more efficient system.

Additionally, training your staff is another necessary collaboration. Training your staff to keep them on the current best practices can help ensure that your practice can mitigate as many denials as possible.

Staying on Time

When it is about denial management, time is of the essence. It is vital to comply with the deadlines put in place by the insurance companies to ensure timely claims filing. A medical practice must adhere to established and validated processes, aiming to resolve denials in a week.

Ending Thoughts

For stronger revenue cycle and denial management in medical billing, the claims denial process must not be limited to a single team or a department. It should be an all-hands-on-deck effort that promotes attention to detail, boosted engagement, and accountability. All of this ultimately contributes to higher first-pass yield and even more substantial practice revenue. The entire process is interconnected, and improving one aspect of your operations can create ripple effects throughout your workflows.

Frequently Asked Questions

The claims rejections occur even before a claim goes in processing, and more often than not, it results from incorrect data. On the other hand, a claim denial is for a processed claim that is found to be unpayable. This condition can arise owing to the terms of the payer-patient contract or for a multitude of different reasons.

In simpler words, denial management is a strategic process that works to identify and resolve problems that lead to claims denials.
Putting a denial management system in place for effective medical billing can help identify reasons for denials. This system can also offer valuable feedback for improving the claims submission processes.