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“Almost 80% of Denied Claims are Preventable”
  • Faster Reimbursement
  • Increase Cash Flow
  • Certified Coding Team
 

Denials Management

Denial Management is extremely time-consuming and most practices (and billing companies) do not devote sufficient resources to adequately pursue maximum reimbursement. According to a recent study by the Health Insurance Association of America, 14% of all claims submitted to payers are denied - that is one in seven that need rework, resubmission, and possible appeal by the provider.

The same study found that six percent of EDI claims are rejected even before entering the payer's claim system, and these are not even counted as denials. Typically only half of all first denials are ever appealed. Studies show that 45 percent of all first denial appeals, 50 percent of second denial appeals, and 10 percent of third denial appeals are won.

Top 10 Reasons Claims Get Denied

  1. Incorrect patient identifier information.
  2. Coverage terminated - Verify insurance benefits prior to services being rendered.
  3. Requirement of prior authorization or precertification - You can attempt to file an appeal but most insurance carriers will not reverse their decision.
  4. Services non-covered - This is another reason why it is important to contact the patient's insurance prior to services being rendered. It is poor customer service to bill a patient for non-covered charges without making them aware that they may be responsible for the charges prior to their procedure.
  5. Request for Medical Records
  6. Coordination of Benefits
    • Other insurance is primary
    • Missing EOB
    • Member has not updated insurer with other insurance information
  7. Bill liability carrier - If the claim has been coded as an auto or work-related accident, some carriers will refuse to pay until the auto or worker’s compensation carrier has been billed.
  8. Missing or Invalid CPT or HCPCS Codes
  9. Timely filing - Be aware of timely filing deadlines for each insurance carrier.
  10. No referral on file - Some procedures require that the patient obtain a referral from their family physician prior to services being rendered.

 

HealthCare Management Solutions standardizes denial capture for all payers and includes recommendations of best practices for process improvement. We also maintain close payer relationships and analyze common payer denials trends. This helps us establish strategies on the front end to ensure the process moves as smoothly as possible.

Key benefits:

  • Improve cash collections both short- and long-term
  • Reduce write-offs and protect revenue
  • Decrease denials by identifying root causes
  • Implement tools and processes for sustainable improvement and transition back to in-house staff

 

Not only will we assist you in overcoming payment roadblocks, our professionals can help improve your revenue management ensuring you get paid for the services you've already provided.



 
Since utilizing HealthCare Management Solutions for training our coding staff now performs much more proficiently within our complex multi specialty practice.
Jill Hall - Director of Business Services @ Northeast Georgia Physicians Group
Copyright © 2017 - Healthcare Management Solutions, LLC.
HealthCare Management Solutions, LLC.
4452 Congressional Drive
Jacksonville, FL 32246