{"id":14162,"date":"2021-08-27T15:24:06","date_gmt":"2021-08-27T15:24:06","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=14162"},"modified":"2025-10-27T11:44:52","modified_gmt":"2025-10-27T11:44:52","slug":"implementing-preventive-denial-management","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/implementing-preventive-denial-management\/","title":{"rendered":"Implementing Preventive Denial Management"},"content":{"rendered":"<p><span style=\"font-weight: 400;\">According to the denial rates report published in February 2021, out of total claims submitted worth $3 trillion, claims worth $262 billion were denied. You will be surprised to know that more than 90% of these denials are preventable. And the worst part is, more than half of these denials were never appealed or resubmitted by providers and healthcare organizations. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">Healthcare organizations should adopt a preventive <a href=\"https:\/\/www.medicalbillersandcoders.com\/revenue-management-services.aspx?DivId=denial-management-appeals\">denial management<\/a> approach rather than a corrective one. Managing denials requires an alarming amount of time, money, and resources; adopting a preventive denial management approach could protect revenue.\u00a0<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Identify Denial Reason<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Process last 12-15 months\u2019 claims submission and denial data to identify denial reason. After identifying the denial reason, categorize the root cause for each denied claim. Some of the common reasons for denials are prior authorization, incorrect coding, timely claim filing, and out-of-network billing. For reference, we shared top coding denials in 2018.\u00a0\u00a0<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>Radiology:<\/strong> MD may have ordered a test and failed to document the reason why the test was ordered many occurrences in the emergency department (ED) and same-day surgery (SDS).<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>Same-Day Surgery (SDS):<\/strong> Electrode removals for leads not working and the complication code not passing medical necessity.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>CCI conflicts with HCPCS codes<\/strong> of 58661 billed with 44970. CPT 59 would need to be added on 44970. The coder is not prompted by 3M to add 59 at the time of coding.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>25:<\/strong> Rejections on evaluation and management (E\/M) levels. Most often, the E\/M level is done in the ED or by another vendor, not by health information management professionals.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>91:<\/strong> Rejections of duplicate lab modifiers on a daily basis. If caught on the front end, could eliminate many edits.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>59:<\/strong> Rejections on a daily basis. Same thing with modifier 59. If caught on the front end, could eliminate many edits.<\/span><\/li>\n<\/ul>\n<h2><span style=\"font-weight: 400;\">Build Denial Prevention Team<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">The next step would be forming a denials prevention team. This would be a multidisciplinary team that includes experts from medical coding, billing, accounts receivables, and providers. Everyone in this denial prevention team should take 100 percent ownership of correcting each denial. This level of responsibility requires a high level of commitment and expertise. So, selecting the right team members with the right expertise is essential.\u00a0<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Provide Training<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Find areas of improvement in your revenue cycle management and provide training. Some of the areas would include technological deficiency, lack of knowledge, process gaps, and documentation. For example, if you find out medical coding is a major reason for denials then provide training for medical coding. Make sure that your coders would have access to numerous resources including software applications and online references. Your coders should understand the payer mix and payer-specific coding guidelines.\u00a0<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Monitor Performance<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Consistently measure the performance of all activities included in the <a href=\"https:\/\/www.cms.gov\/files\/document\/r10505cp.pdf\">revenue cycle management<\/a> process. Monitoring performance will ensure an overall reduction in the denial rates and success of the appeals submitted. Some of the data you should look into include: denial rate, rate of appeals, and appeal success ratio.\u00a0\u00a0\u00a0<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>Denial rate:<\/strong> This will include a number of claims denied: procedure codes wise, payer wise, modifier wise, patient wise, location wise, and rendering provider wise. This level of specificity will help to identify the impact of denial prevention activities over a period of time.\u00a0\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>Rate of appeals:<\/strong> Keep a track of the number of appeals done. Without proper understanding, too many appeals may result in wasting time and money. Understanding root cause, resolution of denial, and appealing with corrected\/additional information is the right way to handle denials.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><strong>Appeal success ratio:<\/strong> The appeal success ratio cannot be too small as it may not justify the time invested by team members of the denial prevention team. Just appealing denials won\u2019t help.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">Most of the practices are aware of the impact that denials can have on their revenue, however, they lack the technology and staff expertise to implement an effective preventive denial management process.<\/span><\/p>\n<p><span style=\"font-weight: 400;\"> Outsourcing to a billing company like <strong>Medical Billers and Coders (MBC)<\/strong>, which has the technology and medical specialty expertise available to optimize your revenue cycle and boost collections by preventing denials. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">To learn more about our preventive denial management process, contact us at <\/span><span style=\"font-weight: 400;\"><a href=\"mailto:info@medicalbillersandcoders.com\">info@medicalbillersandcoders.com<\/a>\/<\/span><a href=\"tel:888-357-3226\"><strong> 888-357-3226<\/strong><\/a><\/p>\n<h2>FAQs<\/h2>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1761565424056\"><strong class=\"schema-faq-question\">1. Why are so many of my claims being denied, and can they be prevented?<\/strong> <p class=\"schema-faq-answer\">Over 90% of claim denials are preventable, with common reasons including incorrect coding, lack of prior authorization, and timely filing issues. Identifying denial trends and addressing them proactively can significantly reduce denials.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1761565439043\"><strong class=\"schema-faq-question\">2. How can I identify the root causes of claim denials?<\/strong> <p class=\"schema-faq-answer\">Review the past 12-15 months of claims and categorize denial reasons such as coding errors, prior authorization issues, or out-of-network billing. This helps pinpoint recurring problems and areas for improvement.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1761565448377\"><strong class=\"schema-faq-question\">3. What is a denial prevention team, and how does it help?<\/strong> <p class=\"schema-faq-answer\">A denial prevention team, composed of experts from coding, billing, and accounts receivable, takes ownership of correcting denials. Their collaboration helps streamline processes and reduce future denials.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1761565464127\"><strong class=\"schema-faq-question\">4. How can I reduce denials through staff training?<\/strong> <p class=\"schema-faq-answer\">Identify weak areas in your revenue cycle, such as coding errors or documentation gaps, and provide targeted training. Ensuring coders understand payer-specific guidelines and have access to the right resources can improve accuracy.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1761565474060\"><strong class=\"schema-faq-question\">5. How can outsourcing help with managing claim denials?<\/strong> <p class=\"schema-faq-answer\">Outsourcing to a billing company like <a href=\"https:\/\/www.medicalbillersandcoders.com\/\"><strong>Medical Billers and Coders<\/strong> <\/a>can provide the necessary technology and expertise to prevent denials. This improves revenue cycle management and enhances collections by addressing issues before claims are submitted.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>According to the denial rates report published in February 2021, out of total claims submitted worth $3 trillion, claims worth $262 billion were denied. You will be surprised to know that more than 90% of these denials are preventable. And the worst part is, more than half of these denials were never appealed or resubmitted [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":14163,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[17],"tags":[],"class_list":["post-14162","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-claims-denials"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.8 (Yoast SEO v27.8) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Implementing Preventive Denial Management Service<\/title>\n<meta name=\"description\" content=\"Denial are one of the most costly revenue cyle drains for medical practice. 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