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Medical Denial Management and Prevention5/26/2022 The desired result for any submitted claim is receipt of payment. The most obvious way to make that occur is to send out accurate claims the first time. This needs attention to detail, which is all about people and procedures—the right people in the right positions authorized with the right training and the right operating actions to make sure coding and medical billing departments run smoothly and professionally. The reality is that even when all the right pieces are in place, medical denials still occur. When they do, the goal is to correct the error, get paid, and determine what actions are required to keep mistakes from being repeated. Once again, the people and procedures in place make that goal reachable. Medical denials should result in the generation of appropriate corrective actions designed to reduce the occurrence and recurrence while improving the detection of failure modes. This process contains the assignment of accountability for completing each of the compulsory actions by a predetermined deadline that complies with insurance company’s necessities. It also involves a reassessment of and rescoring the severity, probability of occurrence, and the likelihood of detection for the top failure modes, and post-resolution evaluation to determine the effectiveness of the corrective actions taken. It all starts with a zero-tolerance mindset for preventable medical denials, most of which are well within the organization’s control, caused by either action or inaction within the revenue cycle process. For example, many medical denials can be easily avoided by ensuring an adequate audit system is in place to verify the claim is accurate before it leaves the building. Examples of the mistakes that lead to avoidable medical denials are missing or invalid authorizations numbers or plan codes and truncated codes.
Some medical denials are destined to occur no matter how diligently the claims are reviewed before submission. The most dreaded of these are the “not medically necessary” medical denials. In this case, the goal is to stay on top of medical necessity medical denials to ensure they are appealed as they occur. Properly appealing a denial may require some research by claim experts and coding professionals and sometimes queries to the providers, but the extra work is worth it to ensure the coding is correct, documentation is adequate, and medical decision-making is appropriate before proceeding. For example, supply the appropriate medical records and, if necessary, include articles, images, or even a letter from the provider to support the reason for the service. Finally, continuously evaluate internal workflows to identify areas for improvement and conduct ongoing staff training to ensure everyone is up to speed. Learn how to run reports to catch medical denial patterns so preventive actions can be taken within the payer’s obligatory time frame—which can be as short as 90 days—and analyze denial data to identify trends, patterns, and opportunities to prevent future medical denials. Read More: How to claim when Insurance Claim Rejected
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