Denials are responsible for major erosion of practice revenues, and, despite the best efforts, denials continue to assume monstrous proportions. The situation has grown so alarming that:

  • Medical practices fail to collect 25% of the money they are owed
  • $125 billion is left in the bag as unpaid claims
  • Only 70% of claims are paid the first time they are submitted
  • Of those denied claims, 60% are never resubmitted to payers
  • Medical practices never pursue 18% of claims at all

While payers (whether Medicare, Medicaid or private health insurance companies) are justified in denying claims with inherent errors, it is physicians who are responsible for not pursuing with resubmission and intensified efforts. This is where Denial Management becomes significant.

Denial Management comprises thorough analysis of denials and ways to convert denials into reimbursements. The crucial part of an efficient denial management practice is re-appealing with substantial proof.But the actual process of your denial management starts with knowing the reasons for denials.

Over a period of time, it has been seen that payers base their rejections on the following:

Registration inaccuracies, wherein either patient’s insurance is not verified or a wrong payer is mentioned or it is difficult decipher patient’s identity
Charge Entry with unacceptable procedure or diagnosis codes
Lack of referrals & pre-authorizations
Inadequate information about patient
Claims with code duplication for the same procedure
Lack of substantial proof for medical necessity of a procedure
Inaccuracies in clinical documentation
Bundling non-allowable items or applying modifiers where they are not permissible
Lack of credentialing

Once you have known the root causes for denials, it should lead you to analyze the extent of denials as against the actual submission. Practice Management System (PMS) makes it easy for you to track down denied claims. The advantage of having a PMS in your practice is that it reflects the exact payment posting against each of the submitted claims making it easy to identify the under realized or denied claims.

Having known the reason and the extent of denial, it is now time to put your denial management skills into practice. While coding revision and modification set the things in motion, it is the relationship with the payers and adjudicating agencies that would eventually tilt the balance in your favor.

But it has been found out the physicians are either reluctant or do not have time to focus on these denial management skills amidst their busy clinical schedule. The fact that their internal staff too lacks these skills has not helped their cause. Therefore, medical billing consultancies that offer to integrate denial management processes into your medical billing practices should offer the much needed relief. – being a proven medical billing consortium offering quality and result-driven medical billing services – across all 50 states for over a decade with experience in handling a varied payer mix - are known for elevating practice revenues through integrated denial management. To substantiate our denial analysis, we follow these steps carefully:

  • Figure out specific causes for the accumulation of the denied receivables. Such denial analysis provides us the characteristics of the denials, and an opportunity to get them resolved comprehensively
  • Analyze the financial impact of the denials; our team of expert medical billing professionals is adept at identifying the general pattern and stake of the denials to evaluate its impact on financial returns
  • Provide feedback to improve the efficiency through root-cause analysis and financial impact analysis of denials

MBC’s unique integrated approach has helped physicians of varying sizes & specialties by interpreting the reasons for denials, increasing resubmission and realization through instant denial analysis and management process.

Published By - Medical Billers and Coders
Published Date - Oct-26-2012 Back

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