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Are you Seeking Ways to Lower Denial Rate

Claim Denials are Getting Common Place

Many practices are facing claim denials – denial has become an everyday hindrance to some. With the industry having transitioned to ICD-10, denial potential has only further increased. The greener side is that several of these denials can be avoided. Following certain diligent processes and putting up a little effort while spending some time, claims denial rate may be brought down to the normal standard of around 3% to 5%.

What’s all the Noise about Monitoring & Mitigating Denials?

There has been more awareness and discussion about claim denials in recent times. This is partly due to the sophistication of algorithms used by payers that enable easy identification of denials. With practices looking for ways to eliminate significant resource and time-related issues, denials have become more of a concern. Moreover, ignorance toward denials often leads to trouble in later stages. These factors make denial handling vital in modern practices. As the potential for denials is expected to increase when the grace period of ICD-10 elapses, practices are developing strategies to face this issue.

Effective Practices that help in lowering Denial Rate and improving cash flow

  • Understand Present denial rate
    • The first step toward managing denial is knowing your present denial rate – work out the figure for a given time period. Calculate denial rate in relation with provider, payer, reasons for denial, location, and specialty.
  • Mark primary reasons for denials
    • Reasons for denial vary with practice and specialty. By basing the major reasons of denial, build an effective strategy of denial management—by mapping these reasons into codes, it would be possible to analyze data and identify the problem’s root cause.
  • Engage certified medical coder or revenue cycle administrator
    • Fully devoted to the purpose, this person will assist tracking denials and thus improving the chances of putting up claims that are error-free, by performing the following:
      • Validating codes chosen by physicians in the EMR
      • Acting as resource for clarifying code combinations, documentation needs, and more
      • Recognizing missed charges on the basis of documentation of progress note
    • Create a multipronged denial team
      • Form a team of varied professionals including a coder or biller, a physician, and a practice manager—the team must aim at the following:
        • Collecting all useful data about denials
        • Reviewing data and identifying the trends
        • Creating a systematic work flow toward denials
      • Educate the staff
        • Proper staff education offers several benefits when focus is set on the following topics:
          • Accuracy in data entry
          • Documentation needs according to ICD-10 specificity
          • Procedures to suit insurance eligibility and coverage
          • Filling out forms appropriately
          • General rules for particular procedures

A clear understanding of denials helps in identifying specific areas that can be improved. This enables practices to act proactively and improve their processes