Denial Management and Resolution

By Stacy State, Director of Marketing, Advantum Health
Twitter: @Advantum

Managing denials can sap limited medical practice resources and cash flow. Establishing an effective denial prevention program is crucial to the long-term success of your practice. The good news is through preparation, training, and education, practices can effectively mitigate the risk of denials.

By identifying the bottlenecks in processes and technology that prevent clean claims and implementing denial prevention best practices, medical groups can successfully reduce denials and increase revenue. Here are three key areas practices can focus on to reduce the threat of denials.

Train and educate staff
Annual training for staff can seem expensive and time-consuming but is well worth the investment to guard against the revenue cycle disruption associated with denials. Rules and processes change constantly. There are numerous inexpensive or even free training programs available to help keep practice staff up to date on the latest coding and documentation requirements and regulatory updates.

Available training resources include:

  • Certification program training and CEU programs
  • Business partner training webinars
  • Commercial and federal payer websites

Medicare offers a comprehensive web-based training (WBT) program through the MLN Learning Management System that gives users free, 24/7 access to courses. CMS provides continuing education credit for most courses. WBTs are updated every 12 to 18 months. These resources represent an avenue for practices to proactively guard against common claims issues through staff awareness of potential problem areas.

Implement pre-service prevention practices
Denial prevention begins before the patient arrives. Predict potential points of vulnerability through post denial data collection reviews. Move processes like insurance verification and patient balance collection or payment plan review to the front end of care episodes to guard against denials.

Pre-service denial prevention should entail:

  • Confirmation of procedure or reason for visit
  • Referral information capture
  • Verification of demographic data at every encounter

Practices should optimize patient registration systems to minimize data risks that could lead to denials. This should include a process for managing duplicate patient records, assignment of required fields as necessary and screening for field format errors. Conduct routine maintenance and IT needs assessments. Maintain a clean payer code dictionary and code crosswalk, clean payer plan codes, and up-to-date national and local coverage determinations.

Safeguard against known issues
Engage providers regarding identified coding issues. Use comparative data to illustrate how errors impact cash flow and educate providers on data collection best practices. Implement denial prevention processes focused on areas where issues are likely to occur, including:

  • CPT modifiers
  • Medical necessity
  • Prior authorizations
  • Taxonomy codes
  • Credentialing

Set up automated processes where possible to reduce the risk of human error. Ensure that electronic insurer edits and electronic copies of payer guidelines are in place to support medical necessity determinations. Move those edits into the scheduling system to make staff aware of what’s required as early in the process as possible.

Learn from past mistakes
Practices should draw from denial data history to tailor in-house training exercises. Produce daily feedback, sorted by location and employee, regarding denials. Targeted re-training programs can then be implemented to resolve identified problems. A consistent audit process will illuminate reoccurring denials and allow practices to put quality assurance processes in place where issues are known to occur.

Every practice should adhere to a standard process for routine internal claim audits. Educate staff and providers on chart minimums and documentation requirements where audits reveal gaps. Once consistent claim accuracy is achieved practices can reduce audit frequency or intensity.

Remember that every denial and audit represent a learning opportunity for practice staff members. By leveraging these coaching opportunities to continually improve workflows and supporting technologies, medical practices can protect revenue streams by significantly driving down denials.

This article was originally published on Advantum Health and is republished here with permission.