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Possible Solution To Optimize Claim Denial Management in Medical Billing

author-img By Arina Smith 5 Mins Read 11 September 2023

Claim Denial Management

Denial of medical claims is a reality that every medical practice is facing in the US healthcare industry. No doubt, re-submitting medical claims is a frustrating and time-consuming process.

That’s why it is essential to build an effective claim denial management system in place. To fastly identify, resolve, recover, and eliminate denied claims. Because the longer a healthcare practice waits to resubmit a denied claim. The longer healthcare service providers wait to get reimbursed for providing healthcare services.

Recent healthcare reforms, i.e, lower payment rates, an updated ICD-10 coding system, reporting heavy value-based reimbursement models. Have made it even more essential for medical practitioners to offset profitability losses or declining revenues by tightening up the denial process. And ensure that they collect their pending payments in an efficient and timely manner.

To start a prevention-focused medical claim denial management solution, healthcare practitioners should;

  • Improve front-end RCM procedures.
  • Implement innovative practice management solutions.
  • Identify and analyze the reason for claim denials.
  • And work denials in a timely manner.

Here are some more possible solutions that help to reduce the claim denial rate and improve claims reimbursement.

Identify the root causes of denials:

Identify the root causes of denials:

The latest report in the US healthcare industry indicates that approximately 90% of claim denials are avoidable. To begin resolving a high number of claim denials, healthcare providers must first understand what is causing this problem in the first place.

So, tracking common denial reasons, pinpointing the reasons why insurance companies deny claims. And moving towards a prevention-focused action plan are key steps to improve claim denial management processes.

Certainly, there are several reasons that undeniably contribute to current and future claim denials. For example; improper patient information, wrong coding, lack of pre-authorization or pre-certification, etc. Identifying and rectifying these problems is the key to preventing denials within a healthcare setting.

However, some of the common reasons behind a medical claim denial can be rectified by correcting claim management workflows, i.e, patient registration and claim submission procedures, etc.

On the other hand, applying denial management tools can be amazingly useful. It will help billing staff to examine claims, so they can discover places for a change. Because when a medical claim gets denied, the billing department immediately addresses the claim and resubmits it as soon as possible to ensure quick and fast reimbursement.

As a result, by quickly addressing common reasons for denials, healthcare practitioners can increase their clean claims.

Use advanced claim scrubbing tools:

No doubt, Identifying the cause and tracking your medical claims for denials are both crucial steps in a denial prevention process. But healthcare service providers should try to avoid potential denials before sending a claim to the insurance company.

By utilizing claim scrubbing tools medical providers can significantly reduce the denials rate. Because these tools help to catch and rectify common billing errors on the spot. It’s essentially a way of auditing claims before they are submitted to payers.

Automated Insurance verification:

One of the most common reasons for claim denial is lack of coverage. This happens when a patient’s coverage has expired or doesn’t cover certain services. Or he/she changes their healthcare coverage but forgets to inform their medical professional.

So, before those services are provided, it’s essential to verify healthcare coverage. With quality denial management tools (EHR systems), automated insurance verification is now possible.

Healthcare practices around the United States have seen a significant decrease in denials after implementing EHR systems that can verify patient eligibility and coverage in real-time. As a result, it will protect your healthcare provider’s time as well as your payment.

File appeals as soon as possible:

When an insurance company denies a medical claim, healthcare practitioners risk losing significant revenue- if this claim is not rectified and resubmitted for payments.

However, every insurance company has different requirements for when a denied claim must be appealed. So, healthcare providers must set a standard procedure for their billing staff to work on denied claims every day. Because engaging billing staff with managing claim denials daily could also help medical practitioners keep track of claims.

Healthcare service providers must create a strong workflow with a process in place which ensures that each denied claim received is rectified as soon as possible or within a week. Because if you fail to resubmit the denied claims within the given time of the insurance companies it will eventually result in permanent revenue loss.

Final Thoughts:

Denial management is a crucial aspect of healthy revenue cycle management and improved cash flow. That’s why healthcare facilities must engage and follow these above-mentioned solutions to remain on top of today’s current healthcare system. And ultimately minimize the potential medical claim denial rate.

If a healthcare practice constantly faces revenue leakage problems. And they find it difficult to manage their billing processes in-house. Then professional medical billing services providing company is one of the best solutions for them. Because these outsourcing companies have professional and well-trained medical billing and coding staff.

By utilizing advanced billing tools and smart strategies they ensure a 100% clean claim rate. The billing experts will track and scrub your medical claims up to 99% while avoiding staff burnout and focusing on your patients.

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Arina Smith

I enjoy writing and I write quality guest posts on topics of my interest and passion. I have been doing this since my college days. My special interests are in health, fitness, food and following the latest trends in these areas. I am an editor at OnlineNewsBuzz.

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