Denial Management Process. Strategies to ensure that claims are received and PAID!!

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1 Denial Management Process Strategies to ensure that claims are received and PAID!!

2 Why is Denial Management critical? The current medical practice s path to survival and success 2

3 . Climbing Cost of Denials to Your Practice Medical practices are failing to collect 25% of the money they re owed $125 billion is left on the table every year in unpaid claims Only 70% of claims are paid the first time they re submitted. 30% are either denied (20%) or lost or ignored (10%). Of those claims, 60% are never resubmitted to payers. Medical practices never collect on a full 18% of claims. 3

4 Example: Recent ENT Practice Audit (S. California) Average number of Insurance Claims in Historical % of practice per year Denials 1 Total number of Average Cost: Financial Impact of Denial denials annually $20 per denial 2 Management to Practice Loss due to denial management (rework of denials) % 2438 $ 48, $ 48, % of Initials Denials Never Paid (written off) 4 Total # of ReWorked Denials Never Paid Average Dollars paid per Claim 3 Financial Impact of Nonrecovery of Denials to Practice Loss due to non-recovery of denials 75% 1828 $ $ 222, TOTAL ANNUAL COST OF DENIALS TO PRACTICE $ 271,

5 Practical ca Exercise Evaluate the denials statistics in your practice (see handout) 5

6 Two Types of Denials AVOIDABLE / PREVENTABLE UNAVOIDABLE 90% 10% 6

7 AVOIDABLE DENIALS Registration inaccuracies Ineligible e gbefor insurance Diagnosis code not valid Charge Bundling Incorrect Modifiers Timeliness Expired Credentialing or Provider Enrollment Medical necessity No N Authorization ti or Referral 7

8 UNAVOIDABLE Medical M l Necessity Additional information requested Unless there are extenuating circumstances, less than 7% claims should be denied on original submission 8

9 90% of denials are preventable 67% are recoverable 9

10 SOLUTIONS 10

11 Eligibility Verification Solution Real time patient information on outstanding deductibles, co-payments and coinsurance requirements This knowledge enables your staff to collect at the time of service or establish payment plans prior to rendering service 11

12 Denial management & decision support tools analyze your remittance advices to identify root causes of denials, zero pays and claims reversals Identify opportunities for process improvements Empower your practice to make informed, data-based d decisions Benchmark your performance against specialty-specific analytics 12

13 HIRE THE RIGHT TEAM In-house billing team or Outsourced Revenue Cycle Management Firm Highly experienced, certified coding and billing gp professionals, specific to your specialty or sub-specialty Up-to-date with CMS and Medicaid options for bonuses, and strategies to avoid penalties. Ability to audit your coding and documentation, and a strong working knowledge of the ongoing g changes in codes, medical policies and industry specific information. Fluent in the complexities of Medicare, Medicaid, Workers Compensation, and PPO carriers 13

14 Steps for Handling a Denial Determine if denial can be corrected and resubmitted or does it require an appeal? Determine if it needs to be written off : is appeal-able or can it be billed to the patient Develop your case based on the payer s guidelines 14

15 DECONSTRUCTING THE DENIAL Denial Reasons and How to Manage 1. 1 Timeliness *(See handouts) 2. Medical Necessity *(See handouts) 3. Other 15

16 AUTOMATE DENIALS What tools are available? What tools can your staff create? Techniques to prioritize Work first with those with the shortest time deadline Know your payers time frames! Create a grid. Prioritize the Highest Dollar amount Method least labor intensive approach appropriate p Correct & rebill Call Fax Formal appeal process If large amount and appropriate, p copy patient on correspondence (cover letter only) 16

17 Thank you!

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