Here’s a riddle for you: What do tax returns, mortgage applications, and search warrants have in common? The answer: If they’re missing any piece of information, they’ll be denied and returned. The number one reason claims are denied is missing information. Just like tax returns, mortgage applications, and even search warrants, claims require a great deal of very specific information. Just one minor error can result in a denial — something every organization needs to be prepared to deal with.
Healthcare organizations risk decreasing cash flow and productivity without a strong, preventive denial management program that gives staff the information they need.
Fortunately, a stronger denial management strategy is within your grasp.
Here are a few common questions regarding denials, along with best practice answers.
1. How can we prevent denials from happening?
A focus on staff training, with an emphasis on patient advocacy, is a great way to tackle denials.
- Train staff to be access experts to improve pre-treatment benefits assessments.
- Develop and share payer-specific utilization review strategies so staff can coordinate approvals quickly.
- When it comes to billing, be sure to designate time for payer-specific research and resource development. Another good training tool? Resources for citing legal protections in appeals and providing ongoing education in contract enforcement.
2. What should we do when we submit a corrected claim with letter and it gets denied as duplicate?
Not surprisingly, this is the second most common reason claims are denied. Here’s some wording that should help when you appeal this denial:
This appeal is to request an audit of benefits applied toward the dates of service in question in order to verify that the duplicate claim denial is correct. Further, we appreciate clarification regarding the date the original claim was paid, the amount of payment, and to whom the benefits were released.
If benefits remain denied, we request a detailed response by a certified claim auditor familiar with the billed procedure(s). Please furnish the name and credentials of the claims auditing, professional who reviewed the denial for compliance with current claim processing standards. Also, please provide an outline of the audit findings as well as specific information regarding benefits applied to this claim and to whom benefits were paid.
3. How do we more effectively track and meet appeal deadlines?
Using a remittance management tool that streamlines your denial workflow and creates personalized work lists based on your team’s roles and responsibilities is a good start. Making sure appeals are automated to eliminate inefficient paper processes while giving you the insight needed to file claims quickly and on time, every time, is another.
To learn more about managing denials, read this eBook more answers: 11 top causes of denials (and how to fix them).
