Denial Management

We at iRCM understand that a good denial management process is not simply about working denials, it is about systematically gathering the data required to eliminate denials. Our Denial management process gathers lots of data and provides the feedback to claim entry team or provider on the updates to prevent the denials in future of same type.

We also understand that achieving powerful results from denial management requires data, data and more data. Our denial management process reports and measures all claims that are being denied by your payers. With this level of data our Denial Management specialists can fix the issues that are leading to the denials (whether it be issues with the claims or issues with the payers) and stop the torrent of unpaid claims into your medical billing process. Once we do this, then revenues for your practice will increase; probably by 10 to 20 percent.

Over the years we have learnt that three elements are typically missing from a practice or medical Provider’s denial management process: data, filtering/sorting methodologies and feedback to systematically correct errors. Most practices & practice management systems do not properly track denials – at least not in the form in which they are typically used (i.e., they may have the capability, but only if properly implemented and used). The practice management systems that do track denials typically overwhelm the practice with data that is difficult to utilize for high level denial management. Finally, even if the data is captured and can be properly utilized, most practices do not have a systematic way to get the information back into the billing process in a manner that prevents the denials from occurring again in the future.

At iRCM, our Denial management Process tracks every claim that has denied and can report this by payer, by CPT, by physician and by diagnosis. This information is presented in a manner that allows fast identification of trends. With this powerful combination in hand, the Practice / Provider of medical service can then utilizes claim rules and edits that are specific enough to dramatically drive up the first pass claim acceptance and stop the flood of denied claims. Our in depth analysis described above also allows payers that are habitual violators of Clean Claim Rules to be identified and pursued. The data and analysis will allow many opportunities for process improvements and revenue enhancement for the practice.

If you implement our powerful Denial Management Solution you can optimize your medical billing and speed up your cash flow. As previously mentioned, our strong denial management solution can increase your collections by 20 percent or more.

As Denial management is a subsection to Accounts Receivables of any medical facility, we religiously follow the below methodology of managing denials from payers. Our solution is focused around the three key fundamentals to effective denial management.

  • Tracking
  • Analysis
  • Trend Management
  • Prevention

Prevention

Prevention focuses on actions that can be taken upstream in the patient encounter to prevent denials from occurring in the first place. Prevention can be introduced anywhere in the patient encounter such as: Pre-admit/Pre-registration, Scheduling, Admit/Registration and Billing. Our denial management experts ensure that we track such trends and keep the Client informed periodically about improvements/process changes that can be made across functions.

Analysis

The process of analyzing and aggregating similar denials is strategic in denial management. The Denial management team at iRCM understands that analysis and segregation is a forerunner to follow-up process and hence for us it is an fundamental step in denial management.

Tracking and Trend Management

Besides keeping a track of the denial trend from payers our experts also actively monitor the payment patterns from various payers and set-up a mechanism to alert when a deviation from the normal trend is seen. This is important in understanding the causes of claim denials and enhancing long-term efficiency and drastically reducing lost revenue.

Some of the Common Insurance Denials

  • Claim denied for Missing / Additional information
  • Claim denied as Duplicate
  • Claim denied for Prior-Authorization / Referral
  • Claim Denied as Inclusive
  • Claim denied as included in Global period
  • Claim denied as not medically necessary / Pended for medical notes
  • Claim denied as non covered service
  • Claim denied for eligibility
  • Claim denied for late filing
  • Claim denied as CPT – Dx mismatch
  • Claim denied / Pending for accident information: (Workmen’s Compensation)

Key Functions of Denial Management

  • Maximize cash flow – Reporting identifies denial causes having the greatest financial impact, thereby accelerating cash flow.
  • Identify the root cause of denials – Collecting and interpreting denial patterns to quantify denial causes and their financial impact.
  • Support accurate workflow priorities and scheduling for follow up – Collecting information on denial appeals, including status, escalation, correspondence with payers, and the disposition of denial appeals to increase recovery amounts.
  • Provide accurate and timely statistics for Management / Clients – Providing management analysis reports and other information to prevent future denials.
  • Track, Prioritize & Appeal denials – Generating appeal letters based on federal and state statutes and case citations favoring the medical provider’s appeal.
  • Avoid out-of-timely filing.
  • Analyze the effectiveness of denial resolutions.
  • Identify business process improvements to avoid future denials