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Top 5 Proactive Denial Management Tips to Reduce Claim Rejections
Medical Billing
  • Apr 12 2024
  • velanhcs

Top 5 Proactive Denial Management Tips to Reduce Claim Rejections

“Denial” – hardly ever is a good word to come across. Especially when you’re at the receiving end of it, be it your visa application, loan application or any application awaiting approval. And this word takes a whole new avatar when it comes to Revenue Cycle Management. Besides just being a metric to measure the success of a firm, it also directly reflects the financial success of the firm.

Claims are highly sensitized documents that require scrupulous scrutiny before submission. It’s almost like walking on thin ice. Claims are denied when they don’t meet a set of required criteria of the insurance company or carrier, thus leading to the rejection of funds to cover for the services provided by the healthcare provider. The set of requisite criteria may vary from one insurance company to another. In essence, they are all similar but not the same. So, an accurately populated template that works with one carrier may not necessarily work with another. Claims that maneuver through the approval process and get the green stamp are called “Clean claims”. Clean claims are a delight to the provider. Healthcare firms dream of achieving and holding a 100% clean claims rate – an aspiration that isn’t even remotely close to how easy as it may sound.

What sounds like a menial task of regular data entry in the front end is far more than what meets the eye. The repercussions can reflect on the financial success of the firm. And, to regulate the discrepancies involved, Denial Management is highly criticalNow, let’s take 5 of the most common errors that stand in the way a clean claim:

1. Medical Coding Accuracy: Incorrect CPT codes can lead to immediate rejection of the claim. The CPT codes translate/codify the procedures involved and help the insurance companies tie the knots together. The recent transition from ICD-9 to ICD-10 further complicates this process.

2. Demographic Accuracy: This is basically collecting information about the patient at the front desk. As simple as it may sound, you’ll be surprised to see how things can at times go amiss. From capturing a patient’s name to getting every digit of the insurance number right, it is all sleet and thin ice.

3. Eligibility Assessment: It is sensible to first find out if a said patient is eligible for insurance or not. This can wipe out a great deal of rigmarole.

4. Claim Duplication: Claims are at time resubmitted. Submitting the same claim twice would result in the rejection of both the claims. So, a potential clean claim can get rejected because of astalking clone.

5. Incorrect POS: There exists a unique 2-digit code for Hospitals, Nursing homes, Emergency rooms, etc. This unique code must match with the respective CPT code to avoid rejection on grounds on incorrect POS.

Now let us take a look at few practices that can help bring down the rejection rates. Strong “attention to detail” is crucial in achieving a healthy claim rate in denial management:

1. Proofreading and Re-proofreading:

Speed can at times impede accuracy and precision. Most typographic errors are retained due to the lack of a third-party review. Having a second pair of eyes review the work can highlight certain errors you may be blind to. Proofreading it once and having it run by another person for a second opinion can help. It may take a few extra minutes, but what it could achieve would save a lot of reiterations in the long run.

2. Demographic Data from Front-desk:

The responsibility of this task will heavily rely on the front desk. Capturing and collecting of accurate demographics, then the transmission of the data to the billing department will be highly critical. If anything goes amiss here, the rest of the process that follows along would be a complete waste of time and resources. It would be ideal for billing departments to work closely with the front desk and check & cross-check the details at each patient visit.

3. Verification of Eligibility:

This is yet another important link to the overarching denial management. This is ideally where the eligibility of a patient is assessed. Normally the billing software would verify this during the patient’s visit.

4. Insurance Company Validation:

As mentioned earlier, this is one of those junctures where things can go awry on multiple accounts. A patient may have multiple insurances and sending a claim to the wrong insurance will result in immediate rejection. The templates may vary from one insurance company to another, so the nitty-gritties need to be validated meticulously before submission. 

5. Insurance Requirements:

Staying abreast with regulatory updates and information pertaining to the industry would be obligatory. Even minor changes can disrupt the entire process and collapse the system. Besides the regulatory changes in the industry even carriers are known to make changes at times. So, it would make sense to stay on high vigil and be sensitive to any news related to the industry or insurance carriers.

The guidelines discussed above can help in further streamlining the denial management process and improve the clean claims rate. For a healthy clean claim rate, the emphasis should be on FTR. And to achieve a healthy FTR the underlying dependencies would require heavy impetus from technology and experienced staff. This is something that many firms lack.

Velan Healthcare Service – Roadmap to healthy cash flow, and successful revenue cycle management.

On the bright side, for the firms that lack the technology and expertise in denial management, there always exists the option of outsourcing. Outsourcing your medical billing to denial management specialists like Velan Healthcare Services is an excellent option. With experience and expertise in the domain spanning across a decade, we’ve seen and taken on almost every possible challenge that comes along the way. Equipped with redundant infrastructure and working round the clock we take it upon us to ensure the delivery of not just results but also values.