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From the Editor’s Desk

What happens to denials?

Insurance denials represent the last hurdle to overcome MANAGE a well-defined denial workflow process efficiently.
in the revenue cycle journey to the reimbursement finish
line. Denied claims represent delayed or lost revenue for • Don’t delay after you identify the denial. Start working
organizations. Addressing the underlying cause of on the resolution.
problems minimizes denials. • Don’t rebill for the sake of re-billing. Focus on resolving
the denial. Creating duplicate claims will only
Despite your best efforts, you will still encounter an compound the problem.
occasional triggered denial that blocks your path to • Choose when to stand your ground. Battling over timely
reimbursement. All too often, it seems that investigative skills filing of claims that are dead-on-arrival to the payer is
rivaling those of the world’s greatest detective are required a vexing exercise.
to provide answers based on limited feedback from the • Build your case by following payers’ guidelines for
payer’s remittance—frequently part science / part art. re-submission. Consider this your “blueprint”
for reconsideration.
Best practice dictates following a four-step process
to IDENTIFY, MANAGE, MONITOR, and PREVENT denials. • Construct a letter that builds your case with
supporting documentation. If the denial is unreasonable,
look for similar denial patterns on other insurance claims
and gather enough evidence to launch a group appeal.
• Be mindful of certain contractual adjustments.
Scrutinize those adjustments before accepting them
at face value.

MONITOR an effective denial management program.
It is more than just the assignment of the employee to
the type of denial.
• Observe the denial reason, frequency, payer, and the
employee’s methodology and productivity.
• Audit the work of employees.
• Evaluate the steps of the appeal process and the
timeliness of the appeal.
• Develop techniques to build an appeal case to the payer
and hold staff accountable for the quality of work and
the outcomes.
IDENTIFY the type of denial by grouping claims into
categories to analyze patterns. Reason and remark codes PREVENT denials from becoming a recurring “crime screen.”
provided by payers require you to decipher and interpret. Profile your payers and look for suspicious behavior that
impacts your revenue cycle, and don’t forget to minimize
A common denial, “CLAIM/SERVICE LACKS THE denials that are self-inflicted.
INFORMATION NEEDED FOR ADJUDICATION,” can lead
you to wonder what the payer means. Denial descriptions The foundation for a denial prevention program is grounded
like this would be akin to a weather forecaster calling for in the forensic interpretation of denial data. Analytical tools
“AMBIGUOUS” WITH A CHANCE OF “OBSCURE.” available on the market today produce root-cause reporting
No one would accept that forecast, and you should and enable you to be proactive instead of reactive.
never accept an ambiguous or obscure denial.

RCM Consulting Services

Contact : sales@rcm-eservices.com