When it comes to effective medical denials management, knowledge is the key. To gain and act on that information, several best practices can be applied to stay organized and informed on the root causes and reasons.
Know the stats:
Knowing initial medical denial, dollar, and the claims rates leads to an
understanding of the reasons for high denial charges and opens new chances to
improve processes and reduce or eliminate problems.
Keep the process
organized: Losing track of denied claims will make you lose money, and climbing
denial rates will lead to some serious issues like bankruptcy. Thus, implement
a prepared denial management procedure that leverages HIPAA-accredited tools
and technologies to track submitted claims.
Act quickly: Follow a validated process to get medical denials corrected, preferably within a week, a goal that is possible when an established workflow is in place to track claims as they enter and leave the system.
Establish a team:
Classify the available resources from all sections and leverage their know-how
to put in place answers and to track and report developments, which will, in
turn, set up standards, reduce backlogs, and help classify root causes. This
robust team of experts would include key members from admitting/registration,
case management, patient financial services, nursing, health information
management (HIM), information technology (IT), finance, compliance, and, of
course, the physicians.
Collaborate with
payers: Payers also benefit from resolving denial issues, so a payer-provider
collaboration can help in addressing them more efficiently, which will also
help achieve system efficiency more rapidly.
Quality over
quantity: The best way to exploit limited resources and time is to follow up
with the medical claims that are already addressed, which will help simplify
more quality claims rather than a higher number of lower-quality claims that do
not yield anything.
Track progress:
Monitoring progress will help differentiate between areas that are doing well
and those that aren’t while allowing for analysis and improving system
efficacy. This helps your organization know which areas are doing well and
which need improvement. Consider automating medical denial management
processes, which also frees more time to rework the refusals.
Conduct
presentation audits: These should include audits of payment advice reviews,
write-off adjustments, zero payment claims, registration, and insurance
verification excellence.
Verify patient information: Leverage patient portals that update patient information and take time to verify that information and the patient’s insurance coverage—while keeping the billing team updated about the policies and educating staff to improve data quality.
Learn from previous rejections: Indecorously established data can be cause for claim rejection, so leverage data including healthcare insurance company and payer ID lists available in electronic health records (EHRs). Tracking and analyzing rejection and denial trends helps differentiate between them, making it easier to learn where problems occurred and fix them quickly.
Meet deadlines: Failing to follow deadlines established by healthcare insurance company policies can affect claim filing.
Know the clearinghouse: From assisting with insurance companies to providing detailed explanations for rejection, maintaining a solid relationship with the clearinghouse will improve processes and benefit both groups.
Understand claim formats: Many healthcare billing companies use EHR solutions to submit medical claims using a standardized format, which can make it easier to identify and resolve problems with denied claims. Claims are often submitted in ANSI837, and information of this allows one to apply ANSI loops and segment references, which is more efficient than sifting through HCFA1500.12
Conduct regular follow-ups: Track every claim so medical denials and rejections can be corrected and resubmitted on a scheduled appeal, preventing revenue loss.
Follow a decision tree approach: A decision tree forces consideration of all possible outcomes and traces each path to a conclusion. This approach helps in training staff to address medical denials more effectively.
Lastly, some
organizations might reflect supplementing internal medical billing and coding
operations with outsourced medical services. Through outsourced services,
organizations can rapidly gain access to a team of highly trained and
accomplished professionals who dedicate their time to interacting with
insurance companies and understanding the reasons behind rejections and medical
denials. Investing in the support of outsourced medical services can also allow
interior teams more time to concentrate on other features of maintenance and
patient experience.
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