The average claim denial rate across the healthcare industry is between 5 percent and 10 percent, according to an American Academy of Family Physicians (AAFP) report.

Reasons for claim denials

The most common reasons leading to claim denials include the inability to provide required pre-authorization, missing documentation, claim form errors inpatient data or procedure codes, duplicate claim submission, claim submission after the deadline issued by the payer, medical procedure not considered as a necessity, ineligibility due to lack of coverage by the payer and use of out-of-network provider, etc.

Prevention of denials

A medical billing company that knows what it is doing will try its best to prevent denials at all cost by employing a number of strategies such as efficient information collection process, thorough proofreading before submission of claims, optimal use of technology, staying abreast with updated insurance requirements and analysis of previously occurred claim denials, etc

Denial Management

However, if the claim is still denied it doesn’t necessarily mean that all is lost. In fact, there’s still room to salvage some or the entire amount from the payer by taking the right steps. That is precisely where denial management comes into the picture. Denial management entails figuring out why your medical claims have been denied, determining the best way to lower your denied claims rate, and implementing strategies to increase your clean claims and boost revenue. Some of the steps we take here at Avernus Medical Billing instead of writing off our denials are discussed below:

Match the reason for denial with your policy

Once you have received and reviewed a letter of denial, follow up as the soonest. Your denial letter should include what’s called an ‘Explanation of Benefits,’ which tells you what your insurer paid and what they didn’t, including a reason why your claim was rejected. It’s important to check the insurer’s reasoning against the details of your health insurance policy. If there is a discrepancy, call your health care provider’s billing office and inform them that the reason in the denial letter does not match your policy.

Submit an appeal

Submission of an internal appeal involves either physically filling out a form supplied by your insurer or sending a letter to your insurer or appealing via telephone/fax/website, outlining your argument along with any mandatory evidence such as a copy of the claim in question and copies of earlier communication to the company about the matter. The appeal must be clear, concise, and factual. If the internal appeal is declined, you also reserve the right to request an external review. In some states, external reviews are conducted by independent review organizations whereas some are conducted by the federal Department of Health and Human Services. Make sure you are familiar with the company’s appeals procedure. When you know your carrier’s policies, you are in a better place to respond to the carrier’s actions.

Be vigilant about the insurer’s notifications

Once your insurer makes a decision, you'll receive notification in writing, which will include details on why your appeal was approved or denied, the basis of the decision, and the next step in the appeals process.

Resubmit the claim in a timely manner

Be aware of deadlines for appealing your health insurance claim denial. Your claim must be resubmitted within the prescribed time frame for it to be effective, otherwise, the claim may be adjudged based only on the information you already provided, or any requests for reconsideration or appeal may be denied as untimely.

Negotiate

Medical bills are negotiable. Once denied, you can often get bigger bills down to a more reasonable rate by negotiating your portion of the medical bill. To be a good negotiator one must possess excellent communication. The negotiator should be well-informed, polite, and absolutely avoid emotional rants.

Track and report denied claims

Tracking and reporting your denied claims will help you analyze your data later if the need arises. Learn which types of denials you’re receiving most and track, measure, and categorize information about your denial trends. Once you start tracking denials, you’ll be able to provide feedback to your staff about what they’re doing right and which areas they need to improve. Keeping proof of your document submissions and changes will make denied claims easier to appeal.

Do you find the task of denial management rather daunting? You need not worry anymore for you’ve reached the right place to relieve yourself from this burden.

Call us at +1 817-989-6949 or send us a mail at info@avernuscorp.com where we are at your service at all times.