Denial Management Primer
Mark Droste

Denial Management Primer

Denial Management Primer

Insurance denials represent one of the most difficult hurdles to overcome in the revenue cycle journey to reimbursement nirvana. Best practice dictates following a four-step process to identify, manage, monitor, and prevent denials.

Despite best efforts, there will be times when a triggered denial pops up like a tight-fisted jack-in-the-box blocking your path to reimbursement. Investigative skills rivaling that of Sherlock Holmes are required to provide answers based on limited feedback from the payer's remittance, often part science part art. Denied claims represent delayed or lost revenue for organizations. Addressing the underlying cause of the problem minimizes denials.

Identify the type of denial by grouping claims into categories to analyze patterns. The challenge is the reason and remark codes provided by the payer require you to decipher and interpret.  Let’s open with one of my favorite denials, "claim/services lack the information needed for adjudication." What does the payer mean? The denial description appears to be like a weather forecast calling for “ambiguous” with a chance of “obscure.”  

Manage a well-defined denial workflow process efficiently. Don’t delay after you identify the denial, start working on the resolution.  Don’t rebill for the sake of re-billing, focus on resolving the denial.  Creating duplicate claims will only compound the problem. Choose when to stand your ground, battling over timely filing claims that are dead-on-arrival to the payer is a vexing exercise. Build your case by following payers’ guidelines for re-submission, consider it your treasure map for reconsideration. Craft 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, and 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.

Prevent denials from becoming a reoccurring crime screen. Profile your payers and look for suspicious behavior that impact’s your revenue cycle and don’t forget to minimize denials that are self-inflicted. The foundation for a denial prevention program is grounded in the forensic interpretation of denial data. Analytical tools on the market today produces root-cause reporting allowing you to be proactive instead of reactive

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