When It Comes to Denial Management, Qualitative Data Is Your Best Ally

When faced with a denied claim, your first question as a physician, biller or consumer should be why?

When faced with a denied claim, your first question as a physician, biller or consumer should be why?

Your best defense against these denied claims, and your greatest chance of winning an appeal, comes from understanding why the claim was denied by the insurer, denial management. Sometimes, the answer is obvious: it could have been a coding error, a duplicate claim or a clerical error. Other times, the reason is far more complex: the physician’s medical decision making is being brought into question, the admission status of the patient is up for debate or the services being billed for are suspect for fraud.

Denial Management and Healthcare Reform

Reform in the healthcare system within the last several decades has put restrictions in place so physicians are no longer to bill for services with the expectation of receiving full payment: generally, the reimbursement is capped based on an estimation of what the service should cost for a particular kind of patient – this is indicated by a DRG or “diagnosis related group”. In medical coding, the DRG helps to determine the amount of reimbursement that a claim could potentially be eligible for. It is then the physician’s documentation that supports the claim and explains in clear terms the medical decision of the physician.

Denial Management and Clinical Documentation

Of course, that is an idea. Sometimes, the dictation isn’t supportive of a diagnosis that could bring about a larger reimbursement, and a coder must code it according to what it supports; thereby losing money unless the physician agrees to provide additional documentation to support their diagnosis. But in a world of mish-mashed records, part paper and part electronic in many hospitals, the coordination of patient records and physician documentation can be a hurdle in and of itself. With more room for error, the potential for denied claims grows larger and larger.

Denial Management poses a challenge for physicians and hospitals alike, but it is essential to diagnose, analyze, and trend the reason behind your denied claims. If you can identify the most common reasons claims are denied, you can take steps to improve in these crucial areas, and hence recoup significant revenue savings.

Denial Management – Billing and Coding

Medical billing and coding, which is undergoing enormous changes with the implementation of ICD-10, is always an area where additional training for staff can be a positive investment in denial management. Providing continuing education for coders can help them be better prepared to identify potentially problematic documentation, and be able to code with the highest level of accuracy.

Denial Management and Continuing Education/Training

Continuing education for physicians, while beneficial, may not be as practical. That being said, the implementation of Clinical Documentation Improvement (CDI) Specialists, RNs who are trained to assist physicians with their documentation, can work shoulder-to-shoulder with physicians who may be struggling to implement EMR use out on the floor. CDI programs may be initially faced with resistance from providers who don’t want to be made to feel they constantly have someone looking over their shoulders, but if symbiosis can be achieved between physicians and the programs, the results speak for themselves!

Using EMR Systems for Denial Management

There are also several electronic management programs that can help hospitals and physician offices track their denials and create datasets and reports that can be tracked month to month. Keeping a close eye on the revenue as well as the qualitative data regarding denied claims is essential to creating cases for appeal and redesigning programs that may be inefficient.

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