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What will you do if your medical claim has been denied? Does it mean the end of the road for getting reimbursed? How do claims get settled after appealing? These are some of the questions asked by those who apply for claims. We have the answers for you. Before that, let's look at what hospital denial management is, as well as claims denial management challenges that pervade the system.

Imagine you are hospitalized for the illness, and after treatment, you are filing claims hoping all is well and your valuable money will be reimbursed because the payer promised treatment coverage with a low rate of rejection. However, the claim is rejected because the patient information was partially furnished. So, you file an appeal and after review, the payer agrees to reimburse the costs for the treatment that wasn't covered earlier. Hospitals constantly think of ways to make the process of rebilling faster and simpler.

What exactly causes claims denial? It is important to understand the challenges associated with denial management before evaluating the best practices to prevent denial of claims.

Top 4 Healthcare Claims Denial Management Challenges

Claims denial is a challenge that most people prefer not to experience. It can also affect healthcare providers because they may be forced to adopt a dedicated system for claims management. The top 4 challenges in claims denial management are as follows -

Claims Denial Rate Is Affected by Varying Payer Rules

Claims Denial Rate is Affected by Varying Payer Rules

The payer may furnish various rules and criteria. Hence, it is important to track denial statistics to lower the chances of rejection. However, obtaining statistics is easier said than done. Payers are often protective of claims denial data because of competition as well as the risk of clients choosing a different payer offering a lower denial rate. All payers follow exclusive, non-standard rules for denying claims as well as a method to communicate with providers.

Using Manual Process for Claims Management Delays Reimbursement

Using Manual Process for Claims Management Delays Reimbursement

Many providers have an inventory of healthcare IT tools to centrally handle operations ranging from patient care to management functions. However, 31% of the providers still handle hospital denial management manually. This can delay the overall time taken for the patients to get reimbursed while pushing the cost for providers.

Claims Denial Reoccur Despite Being Avoidable

Claims Denial Reoccur Despite Being Avoidable

Accuracy of information must remain consistent right from the initial stage where the patient schedules a consultation. However, providers are making the same mistakes over and again resulting in rejection instead of payments. Medical billing and claims management is reactive to the accuracy of the data.

Appealing Claims Eats Away Provider's Time and Money

Appealing Claims Eats Away Provider's Time and Money

Irrespective of the measures taken by providers to avoid mistakes, the chances of claims rejection cannot be eliminated. However, that is not to say providers must stop filing reimbursement claims. In case the claim is rejected, providers can always follow up with an appeal process. However, the appealing process may not be an easy choice. Providers can be set back by tens of thousands of dollars making phone calls, appeals, and investigative work. They can also take a long time to reach an amicable solution.

6 Best Practices for Ideal Hospital Denial Management

Streamlining the claims denial process is a priority for hospital revenue cycle professionals because it boosts revenue generation while making patients feel satisfied. Also, it would give fewer reasons to worry about denials in the future. Our 6 best practices for hospital denial management will help generate more revenue for healthcare organizations.

Here are the top 6 claims denial management best practices for hospitals -

Look for Underlying Reasons for Denial of Claims

1. Identify Underlying Reasons for Claims Denial
When hospitals become aware of the reasons why a provider denied a patient's claim, it can help them prevent similar occurrences in the future as well as improve revenue generation. Not everyone in need of hospitalization is aware of ins and outs of the claims denial system. Hence, it is up to the hospital to educate patients on how their claims will be processed. And for that, Systems Hospital Surveys and Hospital Consumer Assessment of Healthcare Providers are bodies responsible for providing better satisfaction to the patients.

stablish a Structured Approach in Handling Denial Management Process

2. Follow a Structured Approach to Process Denied Claims
One can easily lose money by not following up on denial claims. Without a well-organized way of handling it, it becomes cumbersome to track every denied claim and will eventually lead to a pileup that becomes a headache for hospitals. Occasionally, files can be misplaced or lost which makes matters even worse. Implementing claims denial management technologies is the way to go. Hospitals are turning to technology to prevent claims misplacement. This not only helps smoothen the management of old claims but will also keep track of newer ones. Revenue from denial collection can be placed in the pipeline according to priority and this way, it leads to better revenue collection.

Quickly Process Claims Denial

3. Quickly Process Denied Claims
A successful hospital denial management strategy involves a faster workflow model in handling denied claims. Once the claim is denied by the provider, the onus is on the hospital to ensure that the matter is rectified within a short duration. For that, hospitals will require a bulletproof workflow to register and track claims as and when they arrive and depart their system. This is critical because there is a deadline for hospitals to appeal for denied claims. The validity of the appeal expires if they are not followed up within the time limit.

Follow Up on the Developments and Results at Every Stage

4. Follow Up on the Developments and Results at Every Stage
It is paramount to keep tabs on all the processes because it can help parties involved to observe areas where the workflow is optimal as well as the ones where support is necessary. Hence, for this reason, it is important to preserve records of every claim whether they are paid or not. It is unequivocally important to use analytics to enhance the efficiency of claims processing. The reason for denial, the time required for completion, and time limits are key concerns in claim denial management as we move ahead toward ICD-11.

Track Common Denials as well as Trends

5. Identify Common Reasons for Claims Denial
Tracking common types of denials that hospitals regularly encounter is the key to having a functional denial management process. Although healthcare providers vary, the cause for denials is likely to remain the same. The common reasons behind the denial of claims are as follows -

  • Misspelled names
  • Non-disclosure of pre-existing conditions
  • Delay in Personal Independent Payment (PIP) application
  • Coordination of benefits
  • Incomplete patient information
  • Duplication of claims
  • Missing Personal Authorization Number (PAN)

Although these reasons may seem trivial, they may expose loopholes in the strategy followed by hospitals. Carrying out frequent checks and taking necessary precautions for not just present situations, but also the future will ensure that you are perfectly aligned with the latest trends that will unfold a few years from now. When hospitals plan pre-emptive claims management strategy it will disallow the list of reasons for denial from growing.

Outsource Denial Management to a Servicer

6. Outsource Denial Management to a Servicer
Look for a provider who specializes in denial management services. Before you press ahead on outsourcing the project, it is worthwhile to ask if more money can be pulled from payers and patients, as well as whether the outsourcing company can offer a better experience to help hospitals make their patients feel more satisfied.
When you outsource denial management to a capable servicer, you will be assisted by a team that consists of subject matter experts in the insurance system and the challenges that ensue in the claims process. This will also allow you to focus on other core areas of hospital management.

Outsource Denial Management Services to Flatworld Solutions

Flatworld Solutions (FWS) have 20 years of qualitative and quantitative experience in Denial Management services. We have a team of experienced insurance sector professionals, subject matter experts, and dedicated project managers who can cater to your requirements with precision. FWS is an ISO-certified company with several global offices that are well-equipped with the latest technology infrastructure.

We follow best practices for managing hospital denials so that the reimbursement process is seamless. We ensure the safety of your data by authorizing only qualified professionals to work on the project. If you have time constraints, fret not! We are the people who can ensure the completion of your project within the agreed time limit, in a cost-effective manner.

Contact Us to outsource denial management requirements. Our team will follow up with a customized quote within 24 hours.

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