What is Denial Management in Healthcare?

Denial management is often confused with Rejection Management. Rejected Claims are claims that have not made it to the payer's adjudication system on account of errors. The billers must correct and resubmit these claims. Denied Claims, on the other hand, are claims that a payer has adjudicated and denied the payment.

Healthcare organizations should be concerned about both rejected claims and denied claims. The claims rejection management process provides an understanding of the claim's issues and an opportunity to correct the problems. Denied Claims represent lost revenue or delayed revenue (if the claim gets paid after appeals).

To successfully appeal denied claims, the billers must perform a root-cause analysis, take actions to correct the identifies issues, and file an appeal with the payer. To thrive, a healthcare organization must continuously address the front-end processes' problems to prevent denials from recurring in the future.

Our Denial Management Service Offering

Medical Billing Wholesalers' denial management team has seasoned professionals who:

• Investigate the reason for every denied claim
• Focus on resolving the issue
• Resubmit the request to the insurance company
• File appeals where required

We understand that each denial case is unique. We correct invalid or incorrect medical codes, provide supporting clinical documentation, appeal any prior authorization denials, understand any genuine denial cases to pass the responsibility to patients, and follow-up effectively. We re-validate all clinical information before re-submission.

As an extended billing office, we work with you to analyze your denied claims and reduce denial % over time.

FILING APPEALS

We analyze denial reasons, prepare appeal letters, and refile the claims by attaching clinical documentation and submit the claims via fax appeals in a payer-specific format.

REDUCE DENIALS THROUGH ANALYTICS

Different component processes within the revenue cycle chain can result in claim denials. Often, denial issues are practice-specific or facility-specific. We understand the trends in claim denials and launch an iterative process to reduce them based on specific causes.

Benefits of the A/R and Denial Management Process with Medical Billing Wholesalers

Our full suite of A/R and denial management services offers our clients the following benefits:

• Focus on getting claims resolved. We focus on fixing the claims rather than merely getting the claims status information.
• Process Automation. We cut the effort to check the claims' status by improving the adoption of web portals to obtain claim status online
• Workflow automation. Each claim status code has a set of questions to be answered by the insurance companies to resolve the claim's issues. We have defined our claims follow-up work queues with web-based workflow systems that improve the documentation quality.
• Dashboards and metrics. We generate multi-variate reports to get a clear view of the A/R and focus our effort on the resolution.
• Improving collections and reducing days in A/R. Our clients see a minimum of 20% reduction in days in A/R and improved collections by about 5-7%.