The costs of not correctly managing healthcare denial claims are high and are growing each year exponentially. A big reason for denial management in healthcare is that the case has to do with the complexity of the healthcare industry as a whole. Even under normal circumstances, insurance claims can take weeks to process, payment can take even longer, and medical bills can be inaccurate or unreadable. If you have ever tried to read an insurance form before, you know what we are talking about!
If it is time for your organization to start or improve its processes for denial management in healthcare, it might be worth looking into one of several denial management companies that provide professional services for handling denials and improving billing rates in healthcare. Services such as these can help lower the costs of denied claims and decrease the time associated with processing them. These advantages result in more revenue from claims accepted and allowed versus those denied and sent back by payers.
Revenue flow is critical to all aspects of healthcare operations, including managing claim denials. Non-compliance with various regulations, such as electronic submission requirements, can lead to reimbursement delays and denials, which can significantly impact your medical practices’ bottom line. Recently, federal regulators have increased scrutiny around compliance rates and penalty penalties for non-compliance in Medicare revenue cycle management, which means you need to be especially vigilant about these types of claims. Increased compliance rates will improve your bottom line for many years to come! A perfect solution streamlines claim denial management and coordinate it with daily operations—one that doesn’t require an extensive setup or massive financial investment upfront.
If claims are not processed correctly and efficiently, it is important that claims have been effectively scrubbed. The process of claim scrubbing ensures a claim has all necessary information, including personal data about an insured and a claimant. In addition, scrubbing claims will ensure correct codes are applied, and correct methods are used to notify a claimant that their file is ready for review or payment.
Properly scrubbing claims means isolating all necessary information from an individual claim and using it to confirm correct payment amounts, making sure claim submissions include appropriate medical codes, preventing duplicative payouts, and promptly identifying any overpayments or underpayments. If claims aren’t scrubbed correctly—incomplete or improperly coded, for example—then payments might be delayed or denied unnecessarily, or erroneous payments may be made. All of these scenarios cause unnecessary stress on policyholders, keep them from receiving the payment they deserve, and generally end up costing companies time and money as well.
Before writing a single claim, check with your plan sponsor and any outside auditors for guidelines on handling prior authorization. These policies will vary greatly depending on what’s considered usual and customary and applicable laws. Requesting prior authorization (PA) or similar processes can be time-consuming and annoying, but they are important – particularly in light of high-profile government investigations into potential kickback schemes involving physicians and pharmacies. Without proper processes in place, you may find yourself giving back all of your lucrative PA bonuses or, worse – having your license pulled altogether!
Insurance companies often deny insurance claims, even though they are valid. This typically happens because policyholders do not follow some of their policies’ most essential sections and guidelines. Policies must be read carefully before submitting any claims. It is important to pay attention and not rely on a general understanding of what a section might say. Some common denials include: Not following policy limitations or exclusions when filing a claim, make sure you know what is excluded from coverage, as well as any specific regulations that apply to your coverage.