Denial Management in Medical Coding

Denial Management in Medical Coding One of the biggest challenges in the financial side of healthcare is the need to minimise lost reimbursements and medical denials. This can be a repetitive and time-consuming manual task but with evolutions in accessing big data and new technologies such as AI this could increasingly become a thing of the past.

We are in a technological landscape that is progressing at rapid rates, digitisation of healthcare is already underway. Today there are highly efficient services and systems designed to meet insurance medical claim needs. One of the major problems faced by medical billing companies and healthcare providers is that a large proportion of rejected claims goes unattended, the result is they are not resubmitted leading to millions in lost revenue.

Just because a company (payer) denies a claim, we cannot assume the claim is not payable or there is something wrong with the claim. Errors happen on both sides; the focus should always be on minimising errors where possible.

Every HCP and medical billing company will have some type of Denial Management process. Its sole purpose will be to uncover these rejected claims and also seek to

proactively resolve the issues or problems leading to denials. The aim is to drastically shorten the accounts receivables cycle.

The denial management team in charge of the denial management process often aims to establish a pattern between common denial reason codes against individual payer codes.

This event or trend tracking can then assist to uncover registration, billing, and medical coding process issues. When these are identified and corrected this can then cause a reduction in future denials. For revenue cycle management the impact is to increase the percentage of first submission acceptance of claims. Other elements can be identified such as low-level billing queries that negatively impact payment and even payment patterns and deviations to allow for far more proactive revenue and claims management life cycle.

Appealing for Denied Claims Process Whenever and claim is denied, the next phase of denial management is a process to effectively appeal the denial. This can be time consuming, as supporting documents and the appeal letters need to be formulated and submitted. This also includes information often deeply buried within electronic health / medical records (EMR / HER). Through various digital channels.

The third parties have a vested interest in underpaying or denying payable claims when so much manpower is needed in resolution of the issues. The reality is some practices do not have the scope or time to appeal. By being able to simply track denial management in medical coding, a large proportion of the work can be at least semi-automated.

Patient Follow-Up A large amount of time can be taken doing patient follow up calls. This is usually to identify missing insurance data and patient demographics as well as missing payments. The need is for meticulous record keeping and tracking of patient accounts and follow ups. Yet much of this data may be accessible within the data already held for each patient. Something as simple as contra indications, other medical codes or even wrong medical codes can cripple first time submission acceptance of claims. The ultimate aim is to expedite collections and technology is now at a point where it can shoulder this burden and reduce lost revenue significantly.

Many denial teams are now posting payments via auto remit programs, so underpayments and denials are often automatically applied without a biller or coder questioning the validity of the underpayments or the denials. Checking the medical coding can be the first barrier to mitigate payment denials.