Denial Management Solutions

What is Denial Management?

A lot of claims put forth by patients or providers are denied by the Insurance companies on the grounds of incomplete claim forms, wrong diagnosis codes, incorrect modifiers etc. This is termed as Denial Management.

In the medical billing arena, Denial Management is an indispensable process. Denial management specialists verify and an analysis is done as to why the claim was denied or poorly paid to establish reasons for denial. If remedial actions are taken after the scrutiny, then the claims can be resubmitted for approval.

Why is Denial Management decisive?

This is a major success and survival determinant for any provider’s practice and is a significant path to continued existence and success.

Estimates suggest

  1. Many medical practices are not collecting at least 25% of the money that they are rightfully due

  2. Annually about $125 billion is the unpaid claims figures

  3. About 70% of claims are compensated on first submission. The rest 20% is either denied and about 10% claims are ignored

  4. Many a time about 60% claims are not resubmitted

  5. 18% of claim amounts are not collected by the practices

  6. Established practices face less than 5% denial levels

  7. In actuality, if not for justifying situations, fewer than 7% claims have to be denied on first-time submissions

  8. Most practices witness claims denial between 10-20% and in some extreme cases about 30% of the time

There are two types of Denials

  • Avoidable or avertable
  • Unavoidable

It is said that 90% denials are avoidable, about 67% can be recovered.

Some Avoidable Denials would be:

  • Incorrect registration

  • Insurance non-eligibility

  • Terminated credentialing or provider enrollment

  • Diagnosis code not applicable

  • Bunching the charges

  • Inaccurate modifiers

  • Medical stipulation

  • No consent or recommendation

  • Timely submission

Unavoidable Denials:

  • Medical inevitability
  • Extra data asked for

How do we keep track of denied claims?

  • Identify and determine reasons for denied claims.
  • Handle declarations correctly with the available information.
  • Tackle areas of dilemma by monitoring and computing the available denial data.
  • Assess the number of claims denied based on total claims filed, the money value, the denied percentage calculation, analyzing the same against location, practice, medical specialty etc.
  • Categorize the main reasons for denial like documentation, credentialing, referral system, patient information, registration process and medical history.
  • Create a tracking system with which the practice’s performance can be measured over a determined period of time. With this method any improvement or areas that need attention can be determined.
  • Handle reasons for denial professionally.

Key benefits of Denial Management:

  • Prevent denials, improve cash recovery and increase productivity
  • Pin down claims activity
  • Categorize the drifts, root causes and actual grounds for denial, zero payments and claims reversals
  • Augmented recompense returns
  • Computerized workflow for improved efficacy
  • Supervise people and respective section output
  • Trim down write-offs conveniently
  • Discover process enhancement prospects
  • Develop a performance yardstick against specialty-specified reasoning
  • Allow the practice to make learned information-based choices

With HealthPay Inc. Denial Management services a medical practice, medical practitioner or a physicians’ group can witness:

  • Improved payment recovery by our detailed analysis, and identifying the root cause for denial.
  • Improved in-house productivity, reduced overheads, costs and time-factor savings is a major draw.
  • We adopt the latest technological tools and software to automate the workflow.
  • Constant monitoring, and conduct regular follow-ups with the insurance companies.
  • Complete streamlining of existing processes to aid modifications, resubmissions and preventing future errors.
  • Helps reduce margins of lost income and increase profits.

Our experienced team members are certified billing and coding professionals who can cater to any specialty. We are HIPAA compliant and follow all the latest regulations and procedures. We are up-to-date with the Medicare, Medicaid and other private and state run insurance company rules, norms and various related intricacies.