Denial Management
Services in Healthcare
What is Denials Management Service
Healthcare denial management is a critical process that entails pinpointing the causes behind medical claims denials and implementing strategies to minimize them. A crucial aspect of this endeavor is the proactive implementation of tactics to enhance the rate of initial claims reimbursement.
To achieve effective denial management, it’s imperative to consider the following factors:
Root Cause Analysis
Effective denial management services in medical billing commences with a comprehensive root cause analysis. The most efficient approach to mitigate financial losses stemming from denied claims is to proactively prevent their occurrence. Below are some of the common reasons for claim denials across various medical specialties:
Missing or incorrect information
There are a variety of reasons why this may occur, including blank fields (e.g., Social Security number or demographic information) or incorrect plan codes, to coding errors such as missing modifiers.
Duplicate claims
Submitted claims for a single visit on the same day by the same provider for the same patient.
Provider out of network
In the event that the services are provided by an out-of-network provider, the payer may deny the claim in whole or in part.
Prior authorization
A claim may be denied if prior authorization is not obtained prior to the service being performed. The payer continues to update the list of services that require prior authorization.
Coordination of benefits
If a patient is covered by more than one health insurance plan, claims can be delayed and even denied until the patient’s coordination of benefits is updated.
Medical necessity requirements not met
When a healthcare service is medically unnecessary, the policy does not cover it, and the payer disagrees with the physician about the type of treatment you need for your condition.
The procedure not covered by payer
In most cases, this can be avoided by reviewing a patient’s insurance policy or contacting their insurer before submitting a claim. The payer may deny a claim if a procedure performed is not covered.
Exceeded timely filing limit
When a claim is filed outside the payer’s required days of service, this should be considered when reworking rejected claims.
Get Perfect Denial Management
Assuring that your insurance claims are complete, accurate, and able to be processed by the insurance company is a significant accomplishment on its own, since it prevents your organization from potentially revenue losses.
Here are four more reasons you want to implement Nexus Medical Billing Perfect Denial Management in your practice:
GET A QUOTE FOR OUR PERFECT DENIAL MANAGEMENT SERVICE
Reach out to our experts at WMB for High Quality, Clinically Focused and Cost-effective Denial Management Service