Denial management in healthcare is one of the burning issues for several years. Research and analysis have shown that most of the denials occur due to the fault in the front-end revenue cycle. The second-largest denials come due to invalid claim data processed in the back end. Around 10% of denials are due to the mid-cycle process where authorization becomes an issue. Healthcare organizations are trying to increase their revenue, but due to such denials, it is also becoming tough for them. It has been found out that revenue cycle denial management is dependent on several factors. It has to determine if any insurance claim will come back as a denial or not. Several back-end denials used to occur for lack of procedures maintained in the front end.

To prevent more claim denials on all ends, some preventive measures can be taken in terms of revenue cycle denial management. Here are those:

Front End:

• You have to educate your employees about the entire process and their roles
• Departmental communication should be increased
• The patient scheduling scheme should be streamlined
• Eligibility check should be done regularly
• Price transparency should be implemented immediately
• Time management should have to be executed efficiently
• Automated claim scrubbing must be used
• There can be a 24 hours’ window for manual edit

Middle Cycle:

• Medical coding should have been reviewed
• Training must be given for keeping proper documentation
• The audit process and compliances should be executed

Back End:

• Claim denials must have been kept separately for future analysis
• Conduction of root-cause analysis is mandatory
• Automation in terms of forms and letters are compulsory

If a systematic approach is being taken in this way, then it will be easier to address the issues. Even outsourcing revenue cycle management will also become simple. But the denial prevention can be done and it can start immediately with the employees present in a system. They need to be educated in such a way that they can give solutions to every issue. Their roles need to be aligned as per customer service criteria and every interaction should be in a friendly manner. In fact, after educating staff, the biggest work remains in inter-departmental coordination absence of which reflects in increased denial numbers. The office and billing team must work together for solving any case.

Preventive Measures

There are other ways also to tackle denial management in healthcare. For that, at every end, there should be a to-do list. And automation needs to take the pivot role in repetitive works. For example, every claim information needs to be reviewed before submission. There are two ways – either manually or automatically. Manual intervention might be needed in some cases, but you should have an automated claim scrubbing system. There are solutions available for National Coverage Decisions (NCD), Correct Coding Initiative (CCI), and Local Coverage Decisions (LCD). These allow you to go for customized edits for filtering issues and mistakes. Here revenue cycle management outsourcing plays a big part in implementing denial management process.

Similarly, medical coding should be reviewed wherever possible as this coding plays a huge role in the entire process. Procedure codes are assigned in each stage. These are known as Change Description Master (CDM) and are assigned to a claim based on the charge code issued by the respective departments. Medical revenue cycle management is all about that. Apart from coding, training for proper documentation is another important aspect to look into it. Regular audit and compliance checks must be in place for better productivity.

This is how to deal with denial management in the healthcare industry. These are the only ways to prevent further loss. Then only the entire system will run smoothly.