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Improving Practice Work Flow to Reduce Denials!

July 31, 2013

Getting a denied claim can be quite frustrating for physician practices and medical billers. Majority of denials and rejections are caused due to minor coding error or some issues while filing the claims. Quite often it is the minor work flow processes which prevent a practice from being paid on time.

Most practices believe that the major reason for medical billing denials and rejections are due to coding errors however this is not always the case. In fact few recent industry facts state –reasons for medical billing denials and rejections are majorly caused by failures within the work flow of the practice’s office.

Few reasons for unexpected denials and rejection include-

  • Patient not eligible for benefits
  • Prior authorization required
  • Duplicate claim/service
  • Bundled payment– a benefit of service included in payment/allowance for other service/procedure already adjudicated
  • Claim/service lacks information for adjudication
  • Claim not covered by this payer/contractor
  • Claim sent to the wrong health insurer
  • Documentation required
  • Time limit for filing has expired

All the above issues stated above are related to the work flow process. Instead of resubmitting the denied claim and hoping for the corrected claim to get cleared, it is always better to avoid denials in the first place which can be achieved by improving the practice work flow

Improving the work flow processes at your practice-

  • Checking eligibility : For managing denials effectively, practitioners need to check patient eligibility and verify benefits at front desk during the patient visit itself
  • Identify the type of denial: Check for inaccuracy in the data entered into the system, lack of eligibility verification, incorrect execution of authorizations, clinical errors, or inaccuracy in physician documentation
  • Educate & Train Staff Members : Create a denials-management team to collect data regarding denials, review and analyze data, create reports, and place corrective action plan in process to minimize further similar denials. The team must have a thorough understanding of claims-edit management system, electronic data remittances, and paper explanation of benefit denial reason codes
  • Edit claims: Ensure the set-up of back-end editing (by certified coders), front-end editing (by coders, billers, and medical records department), and prepare appeals to minimise denial rates
  • Incorporate an efficient reporting system : Produce reports in a timely manner to respond to denials or rejections. One can use daily and weekly reports to follow up on individual/group claims and monitor specific problem areas.
  • Monitor the progress : Denials cannot be fully prevented, but can be reduced significantly. This can be achieved by regularly monitoring the progress in the denials management and taking immediate steps to correct any shortcomings
Medicalbillersandcoders.com has been successfully helping clients improve denials management and increase revenue. MBC has been guiding physicians to help ascertain process areas which require up gradation and training. We also offer a complete medical billing solution, with detailed reports and accurate documentation. Our service line deliverables include denial assessment, root cause analysis, and comprehensive management reporting.

Our clients can easily concentrate on patient care and engagement as they rely on MBC for well informed decisions and appropriate tracking of business processes and revenue.


Category : Accounts Receivables / Claims Denials