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The Changing Face of Denial Management

August 22, 2011

Denial management is one of the aspects that affect physicians, health care providers, insurance providers, and patients alike. The major problems faced by billers and coders along with patients are that the insurance companies or payers deny claims based on any reason they can find. This includes technicalities and some aspects such as pre-existing conditions or dropping people from insurance plans because they have an illness.

Insurance companies, being profit oriented, would ideally deny claims based on a genuine cause or even a small point. This loophole has been covered by steps such as allowing children to stay on parents’ medical policy till the age of 26 and reduced denials in case of pre-existing conditions. This aspect essentially means lesser grounds for claims denial for insurance companies and increased revenue for doctors and health care providers. Furthermore, payer responsibilities increase with electronic transactions and insurance companies and payers cannot deny the fact that they never received the claim.

Adding the healthcare IT reforms to this concoction makes a system that is efficient in face of such reforms. The Obama health reform plans to reduce insurance denials even while the doctor-patient encounters increase. This essentially means that the amount of revenue earned by physicians and health care providers is increasing and so is the need for efficient denial management by medical billers and coders. However, the amount of time required for the processing of denial management is also increasing along with the amount of time dedicated by health care providers.

Denial management has acquired a new dimension because of the health care IT reforms and the process is becoming faster and ethical at the same time. Moreover, HIPAA 5010 would also ensure all transactions are in the electronic format and help physicians track reasons for denials easily. This would ensure a steep drop in denials and a greater awareness for physicians in times of increasing work and decreasing reimbursements (proposed SGR cuts) for physicians and health care providing entities. With changing trends of healthcare, the economy hopes to see red tape is avoided in all sectors of health care including Medicare and Medicaid with insurance companies duly and perhaps ethically justifying the denied claims.

Managing claim denials requires relationships with insurance companies as well as physicians along with communication skills and knowledge about various medical terminologies. Medical billers and coders who are experienced in this field can not only efficiently interact with insurance providers and manage denials but also keep up with health care IT reforms and comply with HIPAA guidelines. Efficient denial management by medical billers and coders can ensure the amount of revenue earned by health care providers can increase by as much as 10%.


Category : Accounts Receivables / Claims Denials