If you thought managing denials is all about following up on denials, then you are barking up the wrong tree for sure. Taking care of denials should be a lot more comprehensive and ideally must begin with preventing them from happening in the first place. To understand this term better, it’s imperative to have a look at denial management from a broader or rather an all-encompassing perspective – one which takes provider enrolment, patient scheduling, patient registration, medical coding and clean claims into account. Knowing each of them well and doing them the right way can get you on top of denials and the consequent aging process.

Get Enrolled with the Insurance

If you are not enrolled with the right insurance provider, you will have more payment delays, reduced payments or denials on your plate than you can possibly imagine. So go all out to identify the provider who offers insurance plans that your organization accepts and understand their enrolment process requirements. Else, you may have to deal with a barrage of denials for reasons such as ineligible to perform the services; services performed by the wrong provider type, or services not provided by network care provider.

Having said that, getting enrolled is not an end in itself. It’s also about getting all your specialties and all your locations linked to the provider. This will prevent many a hassles related to denials.

Make Patient Scheduling Error-Free

A payment lifecycle begins with accurate patient information. When dealing with patients, you need reliable information such as patient demographic, visit type, insurance and payment data, prior authorization status etc. You need to have trained employees to check and collect all these vital stats and then run this information through a well-defined process to spot and eliminate inconsistencies. Denials associated with missing or invalid authorization number, no pre-certification; and want of additional information (workers compensation, veterans administration) are rampant, which is why taking full control of patient registration is of paramount importance.

Technology can be of great help in helping providers streamline the process of patient scheduling. You can now build customized rules based platforms to cover a range of scheduling services. Further, you can empower the platforms with embedded conditional logic and rules to ensure nothing falls through the crack. And in the age of analytics, you can even power the platform with analytic capabilities to understand trends and fine tune processes to adapt to new scheduling requirements.

Read Also Strategic Imperative for Denial Management

Focus on Patient Registration

Denials arising because of erred patient registration include services not covered by payer; or services sent to the incorrect payer; or services rendered prior to the coverage or wrong patient identity. Each of these can be avoided by maintaining an updated patient demographics and reviewing a form to clarify the type of terminology that can used for accurate interpretation. For instance, it’s important to determine that patients covered for multiple insurance. The key lies in having an easy to understand registration process and an easy process to record the information.

Technology, again, can provide you with an ideal solution for tackling patient registration effectively. You can leverage it to go paperless and enable  mobile data capture; generate context aware forms; automate the process of populating docs with correct demographic info; automate data validation etc.

Proper Medical Coding

In most cases, payment delay, partial payments, or denials take place because of improper medical coding. This is because, more often than not, the claims made do not reflect the documentation. And the type of common errors in documentation include invalid procedure code, inconsistent procedure and diagnosis; etc. These errors commonly happen because of the involvement of various staff during different touch points of the revenue circle.

The best way to avoid billing denials due to coding is to ensure coding-related stuff are sent to experienced coders for multi-tier reviews. Yet another effective way is to empower the coding and clinical documentation staff to collaborate when a documented diagnosis is inconsistent. Ongoing internal coding quality audits to ensure coders are up to date with AHA Coding Clinic advice can also be very helpful

Focus on Payment Posting

Denials linked to payment posting can happen because of reasons such as contractual agreement; charges exceed the fee schedule or payment is made to the patient. Timely and accurate payment posting assists in identifying the major issues, their reasons along with the course of actions to be taken in addressing them. The most ideal approach is to enter payments within one day or less of receiving receipt, obtain EOBs and Electronic Remittance Advise (ERA) and hand over the claims to the A/R team for follow-up. If there isn’t a systematic way to tackle this then contractual agreements will get reflected as A/R resulting in an overstatement.

The key to ensuring all of these, however, lies is equipping your staff with the right training and tools for discharging their duties. Besides, it is equally important to encourage transparency; keep policies up to date, have a strict monitoring structure in place.


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