The Effective Tips for Denial Management in Medical Billing

Denial management in medical billing.

“Denial management in medical billing” refers to appealing and overturning insurance denials. Denial management in medical billing needs to be proactive to be effective, not reactive. That means billing teams need to address denials before they happen, not just after the fact.

Why denial management in medical billing is so important.

Whether you a small business or a large corporation, a solo practice, or a group of practitioners, you need denial management in medical billing. The claims denial rate in the US is 5-10%. A startup business’s denial rate may exceed 10% and lead to 20%. The reworking cost of the denied claims is also as high as $25. At the same time, the write-off amount is 1-5% of the reimbursements. Figures show the need of denial management in medical billing. As the number of patients, and services increases, it gives rise to the importance of denial management in medical billing.

Denial management in medical billing is significant because you cannot leave the denied claims unattended for long. If you are leaving the denied claims unattended may cause permanent denials. In most cases, you must write off the unsettled claims payments.

At the same time, if the number of denials and rejections increases, it may lead to heavy losses. Repeated erroneous submission can make your practice doubtful for submitting wrong claims, abuse, or fraud. Once accused of fraud, small or large businesses may affect your practice negatively. Trust level of existing patient’s loss and they never prefer anyone to your practice. So, you must consider denial management in medical billing as an integral part of your revenue management cycle. It would help if you kept a keen eye on this section to keep your revenue management cycle financially healthy.

The next question is whether to maintain an in-house denial management team or outsource a medical billing company. Maintaining an in-house team for denial management may require consistent expense and time along with infrastructure and office space.

At the same time, outsourcing a medical billing company for this service can be a good option. Because you only have to pay once to approach trained, experienced medical billing and coding teams. As the medical billing companies keep their billing and coding staff up-to-date about the recent industry changes, the chances of coding errors reduce. Outsourcing a medical billing company is a good option for practice with less space and human resources.

The effective tips  denial management in medical billing.

Here are 10 tips for proactive denial management:

• Understand the reasons of denials.

Denials happen for many reasons, but most can be boiled down to a few key issues: incorrect coding, missing information, and incorrect patient information. Understand the initial reasons for denials. If you understand the reason for denials you can try to prevent them.

• Prevent denials with proper coding.

One of the best ways to prevent denials is to ensure that proper training regarding coding to your medical billing team. Coding is constantly changing, so it’s important to ensure your team is up-to-date on the latest coding changes and updates.

• Implement a real-time claim scrubber.

 A real-time claim scrubber is a software tool that checks for errors in a claim before submission to an insurance company. You can avoid costly delays and denials down the road by catching errors early.

• Follow up on missing information proactively.

If you know a claim is missing key information, don’t wait for the insurance company to tell you – follow up with the appropriate party proactively to get the missing information as soon as possible.

• Verify patient insurance coverage before services rendering the services.

It’s always best to verify a patient’s insurance coverage before rendering the services to the patient. If there are any coverage issues, you can resolve them up front instead of waiting for a denial later on.

• Use technology to your advantage.

Many different types of software and tools are available to help make denial management easier and more efficient. Utilize these tools to your advantage and look for ways to automate repetitive tasks wherever possible.

• Keep records. 

Keeping detailed records of every appeal and denial will help you spot patterns and trends over time. By keeping the records of denials and appeals helps you to use this information to enhance your overall denial management strategy.

• Inform yourself and your team about common denial reasons.

By educating yourself and your team on common denial reasons, you can start to put systems in place to avoid those issues in the future. For example, suppose you know that the reason for claims denial is information. In that case, you can put a process to ensure that all relevant information is collected upfront before a claim is even submitted. 

• Work closely with your provider offices. 

In many cases, denials are due to problems with the way services were documented or coded by provider offices – not by billers or coders. That’s why it’s so important to work closely with provider offices and establish clear lines of communication so that everyone is on the same page regarding documentation and coding requirements.

• Be persistent when following up on denials.

The appeals process can be long and frustrating, but it’s important to be persistent when following up on denied claims. Don’t give up too easily – if you believe a claim denial is wrong, continue fighting for payment until you get the resolution you need.

How you can get benefit from the above mentioned tips

To run a profitable medical business, you need consistent cash flows. For consistent cash flows, you require on-time claim clearance. Hence, denial management is a vital part of your cash flow.

 It is important to submit clean claims to avoid denials. If the claims reject, identify the reason at the earliest and re-submit it for reimbursement. Audit at each step from data entry and coding to once before claims submission can help you to enhance the chances of claims clearance. Multiple verifications like patient verification for insurance eligibility, insurance coverage of the specific service, etc., can help minimize the initial errors in the claims before submission.

The more efficiently you’re billing and the coding team works, decreases denial cases. Proper education regarding the reasons for denials can help you remove the errors or control the reasons.

An effective and efficient electronic health record system can also help you reduce the omission or duplication errors. An efficient electronic health record is also helpful in the electronic submission of claims.

You can optimize your claims denials by following the tips mentioned above.

Conclusion

Dealing with claim denial is time-consuming but it is quite important in keeping your business profitable and reducing your A/R. It would be best if you had an efficient and experienced billing and coding team for the complete billing process and denial management. Building an in-house team may require months to achieve efficiency. At the same time, outsourcing a medical billing and coding team may help you achieve your profitability goals without much tension and depression.