Identifying and Overcoming Challenges in Managing Denials

Physicians and clinical administrators are trying hard to improve and streamline denial management to meet organizational goals. Reducing claim denials is an unavoidable issue. Managing claim denials less than the required quality rate can help in eliminating revenue loss and time spent resolving them.

Denial management should be a consistent process, similar to medical claims that are processed daily. Ignoring denial claims in favor of merely processing new allegations does not nurture the expected financial benefits. Managing denials appropriately and efficiently is a valuable task. Healthcare providers should frame a strategy for denials if they realize that there is an increase in them. 

Identify

The most crucial element to identify is what are the reasons for the denial. It is essential to track each denial and the reason behind it. With this, you can identify any trends happening. Once you have recognized the trend, you will need to analyze the cause of the denial. A trend probably includes a particular payer, location, physician, service line, diagnosis, or CPT code.

Analyze

Many times, denials are the result of something on the front end. Payers don’t have the medical records to base a denial. Are you lacking preauthorization for services? Is there something being put on the claim form wrong? Are you continuously getting documentation requests and practitioners' documentation is unavailable? Is the correct insurance data derived at the time of registration?

Train

Once you have the analysis of the reasons for your denials in your hands, it is time to educate and train your staff. If you are facing denial because the team isn’t getting pre-authorizations, you need to ensure that the team knows what services require preauthorization. If medical record documentation is the reason for denials, healthcare providers need to be trained as per their needs. If you are getting denials because of a non-covered service, make sure registration and clinical staff know about non-coverage.

Monitor

After your staff/providers have been trained and aware, you need to track their performance. You need to ensure that they should follow whatever you have trained them.  Keep an eye on their performance if they are following new protocols, and adhering to new standards created to prevent denials? Sample and audit appeals are to be submitted by denial staff to prove they are following all payer and provider organizational requirements. Observe the trends in this area. It is helpful to consider if any particular provider may be the reason for your denials.

Prevent Once

Now you have recognized, analyzed, and trained your staff. Again you want to set the seal that you have implemented new processes, workflows, and policies accurately to prevent future denials. Share denial reasons with staff and providers openly and continue to certify they have the resources and information required to prevent future denials. Contemplate putting together an expert denial management team that sits regularly to discuss denials. It is helpful to hear ideas from registration, billing, coding, nursing, and providers present.

VLMS Global Healthcare is a leader in managing denials. Once you collaborate with us, we ensure that there will be no stress for you regarding denials.