Denials And Appeals
Find The Root Cause. Address Issues. Get Paid. Focus On Denial Prevention.
What Is Denial Management In Healthcare?
Denial management is a process used in medical billing to identify and resolve claim denials from insurance companies. Denials can occur for a variety of reasons, such as incorrect coding, lack of medical necessity, or missing information. The denial management process involves analyzing denials, identifying the cause of the denial, and correcting the issue to resubmit the claim for payment. Effective denial management helps to minimize revenue loss and improve cash flow for healthcare providers. Common steps in the denial management process include:
- Identifying the denied claims – Review all claims that have been denied by the insurance companies
- Analyzing the denials – Determine the reason why each claim was denied. This could be due to incorrect coding, insufficient information, or a lack of medical necessity.
- Correcting the issue – Take the necessary steps to resolve the issue that caused the denial. This may involve updating patient information, obtaining additional documentation, or correcting coding errors.
- Resubmitting the claim – Once the issue has been resolved, resubmit the claim to the insurance carrier.
- Follow-up – Monitor the status of the resubmitted claim to ensure it is paid by the insurance company.
If the claim is denied or continues to be denied, we must work towards resolving it until it is resolved.
APPEAL
Appeals refer to the process of requesting a review or reconsideration of a claim that has been denied or partially paid by an insurance company or a payer. In medical billing, appeals may be necessary for various reasons, including
- Denial of claim: When an insurance company or a payer denies a claim, it may be due to various reasons such as errors in coding or incorrect information.
- Insufficient payment: Sometimes, insurance companies or payers may make partial payments for a claim, which may not cover the entire medical expense
- Pre-authorization denials: In some cases, medical procedures may require prior authorization from the insurance company or payer, and if it is denied, an appeal may be needed.
- Medical necessity: Insurance companies or payers may question the medical necessity of a medical procedure or treatment, leading to a denial. The appeal process involves submitting additional information or evidence to support the claim, which may include medical records, test results, or a letter of medical necessity. The appeal may be submitted by the patient, healthcare provider, or billing specialist on behalf of the patient. The outcome of the appeal depends on the insurance company’s policies and the supporting documentation provided.
Contact Us
Our Denial Management Services Are Designed To Help Clients Effectively Handle And Appeal Claims That Have Been Denied And Rejected
Our main focus is to resolve the issue of denial.
After resolving the denial of the claim, refile the claim to the insurance company with all the required correction If the claim requires an appeal, an appeal letter will be created and sent promptly with all the required documents.
As we know, every denial has a unique reason. We analyze the exact reason for the denial and make any necessary corrections accordingly. If an appeal is required, we prepare and send it to the insurance company after verifying all clinical information. If a denial requires patient attention, we coordinate with the patient to resolve it according.