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Claim Denials

Every healthcare organization experiences claim denials. It is frustrating, time consuming and expensive to work on denials. But you cannot afford to ignore them. Because denials can hurt your bottomline and increase operational costs! Healthcare experts state that a whopping 25-30% of claims are denied or rejected. Almost 6% of a medical practice’s net revenue walks out of the door every year.

But there is no need to hit the panic button yet. Denials are easy to quantify, address and correct.

Here are 6 ways you can fight back against denials and come out at the other end as a more profitable healthcare organization.

1.  It Is Not Always Your Fault

Yes. A healthcare practice based in Warren, N.J, was repeatedly receiving denials from a payer that didn’t make sense. After several rounds of phone calls it was finally discovered that the insurance company had an edit wrong in its system. Moral of the story? Make sure that you follow up with payers closely to find out if there are flaws in their systems and processes.

2. Pay Attention To Controllable Denials

Claims that are denied for late filing, missing information, uncovered services or outdated CPTs can be easily managed and prevented. Maintain a checklist of claim submission guidelines and deadlines, and tick every box before submitting claims!

3. Categorize Denials

Classify them based on denial code, reason, payer, frequency, and value of claim. After categorizing claims organize denied claims into error categories such as missing NPI/ coding issues etc.., Drilling down into the details will give you a clear picture of where the fault lines are and make course corrections.


4. Monitor Your Denial Reversal Rate

Track your resubmission and appeals success rate to ascertain that your denial management process is on even keel. Check whether your workflow is clearing denials and producing cash. Redesign your denial management workflow if too few claims get paid.

5. Create A Standard Denial Management Workflow

Ensure that the new workflow is clearing up backlogged revenue, has a positive impact on denial volume and whether all payer denials are impacted by the new workflow. Track results closely to know whether further changes are required.

6. Track Metrics

Imagine playing a videogame without a scoreboard. Boring and pointless right? The same can be said for a denial management strategy that doesn’t follow metrics. Track denial appeal rate, baseline KPIs, initial denial rate KPIs and terminal denial rate KPIs. What doesn’t get measured doesn’t get managed. Manage your denial rate better by monitoring vital denial metrics.

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