Shift the Focus from Denial Management to Denial Prevention

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Shift the Focus from Denial Management to Denial
Prevention
Medical billing denial is the constant headache
for providers that negatively affects your
organization's revenue, cash flow, and
operational efficiency. It is observed
that medical billing denial rates range from
5-10 in medical practices while better
performers averaging 4.  Some organizations
even see denial rates on first billing as high as
15-20 and those providers need to rework on one
out of every five medical claims. The rework on
the denied claims costs an average of 25 per
claim and the success rate vary from 30 to 98
based on the capabilities of your denial
management team. You can easily get out of this
headache, if you adhere to policies and
procedures on which the billing staff can be
trained on or you can outsource your billing to
us and rest assured. Medical Billers and
Coders have a 95 clean claim submission rate
which can enhance your revenue and reduce rework
drastically. In this article, some tips are
given which help you to shift the focus from
denial management to denial prevention. Lets
understand them in detail Know the magnitude of
the problem
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Shift the Focus from Denial Management to Denial
Prevention

• You should adopt a framework of iterative
  processes that can reduce the denial rate
  consistently. While making this framework you
  need to understand the magnitude of the problem
  at hand which can easily be understood with the
  help of the following measures.
• Denial Rate
• of high dollar value claims that have been
  denied as a of the total number of denied
  claims. 
• of claims appealed
• Understand reasons for denial
• Here are some claim denials based on common
  reasons are given below
• Prior authorization 
• You practice as well as patients suffer if you
  neglect to get pre-certification (or
  pre-authorization, or whatever term the
  particular insurer uses) as it can cost your
  practice and your patient's money. Also, it can
  seriously decrease patient satisfaction hence
  knowing which insurers require pre-authorization
  and for what is essential.

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Shift the Focus from Denial Management to Denial
Prevention
Insufficient or incorrect information Simple
clerical errors, such as a patient's name being
misspelled, or digits in an ID number being
transposed are often lead to claim rejections
(which don't usually involve the denial of
payment).You can easily fix this but these errors
prolong the revenue cycle, so you want to avoid
them at all costs. Timely filing
issues Different insurers impose different
deadlines for claims submissions, and they have
different policies about what you can do when you
miss a deadline. It is observed that a phone call
will clear all delayed claims submission but in
others, you may have to fill out more
paperwork.  Use of Out of the network
provider  Year to year there may be a change in
insurer networks and patients may unaware of it
or that changing insurance companies may change
medical providers that patients can see and get
full benefits. During appointment booking or
registration your billing staff get patient
insurer information that can allow your billing
staff to determine whether your practice belongs
to a patient's insurer network, and if not, what
sort of benefits (if any) the patient can expect.
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Shift the Focus from Denial Management to Denial
Prevention
Duplicate claims Duplicate claim denials are
considered as one of the top billing errors and
in the case of Medicare, duplicate submission of
claims harm provider in cost, valuable time, and
resources. When more than one claim is submitted
from the provider for the same service, same
patient, same date of service called a duplicate
claim. In most instances, the claim was already
processed and paid or it is an exact duplicate of
a previously submitted claim. Measuring the
success of your denial management program When
you want to measure the success of a denial
prevention program, you should measure the
overall reduction in the denial rates and success
of the appeals submitted. On a short-term basis,
claims resubmission and success rate rates act as
a good sign but the end goal is a considerable
change in the denial rate. Finally, nobody
likes to work on denied claims and it increases
the time to get paid for services hence there are
many steps apart from the above which minimize
the risk of claim denials. Continuous dialogue
between patients and insurers, skilled coding prof
essionals, and front desk staff as well as
exceptional medical billing processes can all
help to focus on denial management to denial
Prevention.