What are denied claims?
Denied claims are basically the refusal of a submitted medical bill or repayment request by a payer or an insurance company. A denied claim refers to the denial of the requested payment for medical services or procedures.
Claims Denial
1- Denied claims hurt the financial health of any practice.
2- The average claim denial rate has amplified by 23% as compared to four years ago. This is concerning.
3- Denied claims affect the practice’s finances.
4- This is mostly due to incorrect submission of claims or denial management.
5- Providers need to assess their claim submission strategy and look for the common reasons their claims end up getting denied.
This article aims to highlight the most common mistakes in denial management so that your practice can avoid them in the future.
Recognizing the Problem
In order to reduce the financial damage created by a denied claim, the best strategy is to prevent them.
According to MGMA, the key is discovering the most common reasons behind denied claims:
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- Absence of pre-authorization
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- Incorrect or missing data
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- Incomplete medical necessity requirements
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- Out of network provider
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- Coding errors
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- Duplicate claims
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- Insufficient documentation to support the provided services
Denial management
When faced with claim denials, providers should regard them as opportunities for growth rather than impassable barriers. It is critical to have a complete appeal procedure that includes timely and well-documented appeals. Additionally, developing open communication lines with payers can aid in settlement and give insight into potential areas for development. Providers may improve their procedures, boost compliance, and eventually lower the chance of future claim rejections by learning from denials.
Best Practices to Prevent Denials
Knowledge is power, when it comes to management of claims denials.
There are several best practices that can be implemented to manage denials:
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- Ensure that your staff is fully trained regarding coding guidelines, documentation and payer policies.
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- The staff should be well aware of the dollar, claims and denial rates.
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- Categorize and quantify denials by evaluating, recording and tracking the trends.
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- Follow an authenticated process to get denials improved, preferably within a week.
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- Establish and adhere to pre-authorization protocols for services and procedures that require approval from payers.
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- The best way to make the most of limited time and resources is to follow up with the claims that are already addressed.
Claim denials may be a constant challenge in the healthcare industry, but they are not unbeatable.
By understanding the complexities of denial reasons, applying preventive measures, and leveraging technology the providers can manage claim denials.
At Erian Billing, our experts handle the denied claims by using best practices and technology.
We strongly focus on staff training and keeping billing and coding professional up to date.
Contact us if you are claims are not getting paid!
