Medical Billing

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denial management services

10-Step Process of Denial Management Services

Ever wondered where your revenue goes even after having a massive patient base? There may be many expenses your healthcare facility might be bearing but one aspect that is crucial to generate revenue is filing claims. For insured patients, claim applications are sent to their respective coverage holders and they make the payment after passing the claim. However, oversight in this aspect may result in substantial revenue leaks. This is where your efforts are wasted. So what can you do? Simple, consider professional denial management services.

Claim filing demands much of your time because it does not involve only submitting applications but keeping track of payments and resolving payer issues on rejected claims. So this part of RCM should be managed with full attention since your revenue depends on this.

Today, we will see what steps expert denial management services implement in your facility. You will know everything about their approach which will make it easier for you to comprehend the importance of professional claim handling. Let’s learn about this must-have service for your facility.

Daily Denial Rejection Scenarios

person sitting tensed

In order to understand denial management services, it is essential to first know why you suddenly start thinking about these services. On a daily basis, a facility files hundreds or even thousands of claims. Due to the pressure of workload manual claim submission results in numerous repetitive mistakes that set the foundation of lost revenue. 

If this problem is not recognized at the beginning, you will keep losing your payments. So what is the point of running your facility when you don’t manage its finances? Let’s see some of these errors that happen normally during claim processes.

Lack Of Patient Coverage 

A patient needs to be confirmed that their insurance covers certain medical procedures before starting the medical treatment. When the claim reaches the insurance payer, they review if that patient is eligible for the service. But when they are not, claims are rejected straightforwardly.

Incorrect Patient Information

Patients make up a big portion of billing. 90% of the processes need their involvement. Another reason that a claim is denied is that filed claims don’t mention accurate patient information. Common omissions include mistakes in name spelling, wrong home address, incorrect bank details, or wrong date of birth.

Missing Treatment Details

CPT and HCPCS codes are used in billing based on which claims are prepared and submitted. But when any code is written wrong in the claim, insurance payers identify it quickly and deny the application. So using inappropriate codes, modifiers, and treatment details is another trouble for the billing department.

Claim Timeline

One minor yet crucial mistake that billers make is that they don’t keep claim filing deadlines in mind. When a bundle of claims is to be submitted, it may take time to send applications to each insurance payer within their specified time. This results in the expiry of claims and thus loss in revenue which you could receive if you have kept submission dates in mind.

Duplicate Billing

This happens when a patient receives multiple health treatments. So instead of filing claims for each service one time, billing responsible staff sends double claims for a single treatment in place of two separate for each. So when an insurance payer has paid the bill for the same service, why would they pay again? This may demonstrate your facility as a fraud so beware of this mistake.

10-Step Process Used By Denial Management Services

a worker in an office

As we discussed above some of the issues that result in revenue loss, let us provide you with an approach denial management services implement. They have a pre-built plan to deal with your facility’s billing and claim tasks. So here is a 10-step methodology they use:

Step 1: Recognize The Reason Behind The Claim

First, they spend proper time knowing your weak areas that are causing your claims to be rejected. They find repetitive patterns to understand where you might be lacking and where they need to focus more.

Step 2: Streamline The Process

Based on the findings, they design their process to streamline management. Here all old-fashioned claim management techniques are eliminated. Instead, most of the time they work towards automation. It helps in preparing, processing, fixing, and tracking claims automatically by using specific systems.

Step 3: Implement Correct Coding & Documentation Methods

Once denials are analyzed, denial management services conduct the right coding for current claims. They even work on patient documentation to ensure their accuracy. These 2 things together set the foundation of a claim. They translate appropriate patient treatments to specific codes which is a must for approved claims.

Step 4: Develop Customized Solutions

Besides handling the claim filing department their staff works on the root causes of the denials found during the analysis phase. They create a customized plan according to weaknesses. This plan then caters to denials as a whole and reduces the rate of rejection.

For example, if their staff has found that most of the denials occur due to coverage verification issues, they will install updated RCM softwares that will take and store patient information in the system and enable you to establish quick contact with the insurance payer to find out medical services come under a patient’s coverage.

Step 5: Deploy Technology

Nowadays not having technology wastes your denial management efforts. People working to handle your claims employ improved RCM and billing software to conduct automated medical billing. This reduces the chances of denials because of the professional handling of bills and claims at every step.

Step 6: Enhance Communication

One of the biggest solutions implemented by denial management services is that they keep close contact with the insurance payers. This way they can know what mistakes they see in your claims that they reject the applications. This communication also helps in quick patient eligibility verification without executing this procedure through automated software.

Step 7: Monitor Denial Metrics

Another crucial task to reduce the denial ratio is to set some KPIs. When a goal is benchmarked it is more likely to be achieved. So staff providing denial management services establish some metrics to be monitored i.e. denial rates per day, top denial reasons of the week, etc. This results in a more dedicated approach to solving the problem. 

Step 8: Provide Ongoing Support

Other than their management tasks, they keep advising other healthcare staff and workers on the latest billing handling trends. This way not only claims but other aspects of billing are perfected, and as a result, your facility builds reputation swiftly.

Step 9: Optimize Revenue Cycle Workflows

They also emphasize the correction of the revenue cycle of the healthcare facility. After all, when the process seems to be error-free from the start, at the time of claim submission there will be less chance that there is an inaccuracy.

Step 10: Measure And Report Results

Last but not least, when all the efforts are done they are measured to see if they worked or not. They conduct regular reporting of improvements as well as areas where it still needs attention. This step shows the efficiency of denial management services and the total revenue generated after using their techniques.

Tools And Software They Use

girl analyzing paper

Denial management services are incomplete without using software and management tools. Here are some examples of what kind of approach they use to prevent your facility from revenue loss:

  • Denial Management Software: offers extensive features for monitoring, controlling, and addressing denials of claims.
  • Revenue Cycle Management (RCM) Software: combine the capabilities of revenue cycle management with those of denial management. 
  • Electronic Health Record (EHR) Systems: provide access to patient health records, documentation, and coding information, which is essential to the management of denials.
  • Claims Scrubbing Tools: assist in finding mistakes and discrepancies in claims prior to submitting them to payers, lowering the possibility of denials brought on by incorrect coding, omitted information, or problems with compliance.
  • Payer Portals and Online Resources: are supplied by insurance companies and are used to communicate with payers, access denial information, and file appeals.
  • Analytics and Reporting Tools: give denial management services the ability to monitor and analyze key performance indicators (KPIs), analyze trends in denials, and produce insights that can be used to improve processes.
  • Document Management Systems: make it easier to store, arrange, and retrieve records pertaining to payer correspondence, appeals, and claim denials. 

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    Protect Your Bottom Line

    If you own a facility in today’s complicated healthcare landscape then it is a must to partner with companies providing expert denial management services. You won’t believe how much you will save after wasting money on useless denial techniques as used by others. 

    So find a perfect service provider for your hospital or clinic and rest assured; your claims will be managed and you will get more revenue than you might have been losing in previous days.