Overcoming Claim Denials and Rejections

Insurance reimbursements form the core revenue stream for most medical practices, making it imperative to meticulously track claims and investigate the reasons behind denials. Failure to follow up on denials will inevitably lead to repeating the same mistakes that resulted in those denials, while missing opportunities to legitimately increase revenue through appeals.

Denial management is an integral part of the revenue cycle. In some cases, practices are forgoing substantial amounts of money because processing denials requires more effort than some are willing to try.

Experts advise that even the smallest practices should implement a claims tracking process. Not only does this facilitate appeals, but it also alerts the practice to internal issues or patterns that may be contributing to certain denials.

Key Denial Management Strategies to Boost Healthcare Revenue

Denials are a pervasive revenue cycle challenge, with denied claims often leading to delayed reimbursement. Keeping track of the reasons, timing, and sources of denials is a daily struggle. Health systems must proactively address this growing dilemma to prevent revenue leakage.

Implementing effective denial management strategies reduces revenue loss, strengthens operational efficiency, and enables healthcare organizations to maintain a strong financial foundation for delivering high-quality care.

This blog presents a comprehensive list of essential strategies to optimize denial management processes, minimize revenue losses stemming from claim denials, and ultimately bolster the overall financial health and performance of healthcare organizations.

Prioritize Denials Management

• Designate a specific staff member to specialize in investigating denials and handling appeals, separate from regular claim processing. This "denial manager" should have a tenacious mindset to thoroughly research and follow up on denials.

Monitor Accounts Receivable (A/R)

• Review A/R monthly to identify any unpaid claims over 60 days old. Ensure these were filed correctly and are being processed, as most insurers have 90-day filing windows.

Analyze Patterns and Red Flags

• Persistent underpayments or denials for certain claim types should be investigated, as they may signal internal coding, documentation, or submission issues that need correction.
  Sometimes providing too much information can lead to downcoding - be strategic about what codes to include based on insurer policies.

Pursue Appeals Diligently

• No valid appeal opportunity is too small, especially with electronic resubmission processes. Over 50% of appealed claims get paid.
  Follow up with payers on appeals status. If denied, consider involving the patient to advocate with their insurance plan.
  Patients can also request external reviews through state insurance departments if appeals are denied.

The experts emphasize a proactive, multi-pronged approach - dedicating resources specifically to denial management, vigilant A/R monitoring, pattern analysis, judicious code submission, and persistent appeals with patient involvement as needed. Optimizing this process can substantially improve reimbursement capture.

Why are Claim Denials Happening?

Here are the top reasons for denials,

Incomplete or Inaccurate Information

• Missing or invalid data fields (Social Security numbers, demographics, plan codes)
  Absence of required modifiers (two-character codes indicating service changes)
  Misspelled names, missing dates (medical emergencies, condition onset)
  Incorrect patient details (date of birth, gender)
  Omitted claim numbers, insurance details, group numbers, diagnosis codes

Eligibility Issues

• Failure to confirm patient's insurance coverage and understand their plan
  Simple errors like misspelled names leading to incorrect patient lookup

Lack of Medical Necessity

• Payer disagrees with the physician's assessment of the necessary services to treat the condition

Coding and Modifier Errors

• Mismatched diagnosis and procedure codes
• Failure to correct coding mistakes before claim submission

Uncovered Services

• Services deemed outside the approved list of covered procedures by the payer

Missing Prior Authorization

• Lack of required pre-approval for certain procedures/tests (64% of physicians unaware of requirements)

Untimely Filing or Resubmission

• Claims submitted outside the payer's designated time window, including appeals/adjustments

How can AEGIS Help?

Claim denials are expected to keep increasing, both in terms of frequency and reasons. So, What’s the good news for healthcare revenue cycle managers? You can get claims paid with smart use of technology—it’s already happening.

AEGIS' Denial Management AI Tool can maximize reimbursement velocity and strengthen your practice's bottom line.

It’s a tool that changes the denial management workflow, clinicians and hospitals can reduce the chances they have denials in the first place, improve their revenue streams and reimbursement rates with no bottlenecks, and ensure that patients get the care they need and deserve without hesitation.

Let’s learn more about the unique features of AEGIS’s Denial Management AI Tool (DM-AI):

• Keeps track of and sorts all denials according to CPT, insurance, and ANSI codes.
  Shows denial trends and patterns visually to lower the denial rate and end global denials once for all.
  Offers ANSI reason codes, payer-specific codes, and descriptions.
  Uses Denial Resolution Strategies (DRS).
  Sets a 24-48 hour timeframe to resolve denials and resubmit resolved claims.
  Document and learn from successful denial resolutions.
  Integrated with the top 25 EHRs/EMRs and Clearing Houses to gather denial data.

In Conclusion

Proactive denial management is crucial not just for boosting financial performance, but also for improving the overall operational efficiency of healthcare clinics. Healthcare denial management automation tool is one of the most pivotal tools for maintaining predictable cash flow and effective revenue cycle management. Denial management services involve identifying the primary issues that generate claim denials, categorizing them based on cause and source, and implementing an effective denial management automation strategy.

Want to discover the power of automation in Claims Denial Management?