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Denial Management by
Uniserve RCM

Denied claims represent billions of dollars in lost revenue for the US healthcare sector. Effective denial management in medical billing and coding can plug the leaks draining your revenue flow. It’s essential to work with experts who can take over the time-consuming task of resolving medical billing accounts receivable (AR) denials and deliver real results.

Today, three out of five claims require denial management. And an efficient denial management process in medical billing is quite essential, especially when it comes to maintaining a steady cash flow, minimizing revenue loss, and improving the financial health of providers.  

In short, denial management can be explained as the strategic process of identifying, managing, and resolving denied claims to ensure every claim is reimbursed. With the right and proper approach, healthcare providers can significantly cut down on their denials, streamline their operations and increase profitability.

Types of Denial Management 

There are 5 types of denial management and understanding them is important for any successful healthcare business.

Hard Denials

These denials are irreversible and lead to lost revenue, often written off completely. While they typically cannot be undone, some hard denials may still be appealed if they result from errors.

Soft Denials

Soft denials are temporary and reversible with appropriate follow-up. They may result from missing or incorrect details, coding issues, or charge discrepancies, and generally do not require an appeal to resolve.

Preventable Denials

It is no secret that preventable denials are a subset of hard denials caused by avoidable errors from the medical practice, such as late claim submissions or incorrect coding. Preventive strategies can help minimize these losses.

Clinical Denials

Clinical denials are hard denials based on medical necessity or levels of care. These denials often involve strict guidelines from insurers, making it challenging to reverse.

Administrative Denials

Administrative denials are soft denials that can typically be appealed. They stem from issues that insurers specify, which can often be corrected, allowing claims to be processed successfully.

Why Denial Management Matters

Today more than 50% of healthcare providers end up losing money for improper denial management. Medical claim denials can lead to delayed payments, and at the same time add administrative costs and a potential decrease in patient satisfaction. A proactive denial management strategy is thus extremely crucial for a successful practice where you address the root causes of denials, whether they stem from errors in coding, insufficient documentation, or missing patient information. By understanding why denials occur, healthcare providers can implement processes that prevent future occurrences, saving valuable time and resources.

Key Steps in Denial Management

Root Cause Analysis

Tracking and Monitoring

Claim Re-submission Appeals

Preventative Measures

Benefits of Professional Denial Management Services

Improve cash flow and revenue cycle performance.

Increase claim acceptance rates

Lower administrative burden in-house

Ensure compliance with changing regulations

How Uniserve RCM Identifies and Work on Improving Denial Management

Denial management in medical billing relies on the IMMP process —Identify, Manage, Monitor, and Prevent—a systematic approach to reducing and resolving claim denials easily.

Step 1: Identify

The first step in denial management is identifying the specific claim denial and its reason. Payers often provide Claim Adjustment Reason Codes (CARC) along with an explanation of payment. These codes can be complex, and so a lot of attention is needed. During this phase, a skilled medical billing specialist or coding professional interprets the payer’s feedback, ensuring a clear understanding of the denial’s root cause. Although time-intensive, this diligent approach is essential for accurate resolution.

Step 2: Manage

Once the reason for denial is identified, the next step is to address and appeal the denial effectively to secure payment. The IMMP process offers structured actions to manage this phase:

  • Direct Routing of Denials: Coding-related denials are routed to the coding team immediately, using automated tools to organize denials into worklists, and thereby allowing for quick action.
  • Organizing Work by Priority: Using denial management software, teams can sort denials by factors like amount, time, and reason, streamlining workflows.
  • Standardizing Processes: Create standardized responses for common denial types by documenting frequent denial codes and establishing action plans for efficient handling.
  • Utilizing Checklists: Checklists of best practices help ensure the denial process remains systematic and minimizes errors.
 

Step 3: Monitor

In the monitoring stage, it’s crucial to maintain a detailed record of denials by type, receipt date, appeal date, and outcome. The denial management team’s performance is audited, ensuring they have the tools necessary to resolve denials quickly and efficiently. Monitoring provides insights into denial patterns, enabling providers to understand trends and strengthen relationships with insurers to reduce future denials.

Step 4: Prevent

The final phase, prevention, focuses on proactive measures to reduce future denials. After gathering data on common denial causes, a prevention strategy may include retraining staff, refining workflows, and adjusting processes. This collaborative effort across teams minimizes the errors that contribute to denials, such as registration errors, missing authorizations, or issues with medical necessity.

 

Why Choose Uniserve RCM for Denial Management?

At Uniserve RCM, we provide end-to-end denial management solutions tailored to healthcare providers’ needs. Our expert team easily identifies and resolves claim issues swiftly, ensuring higher recovery rates and guaranteeing faster reimbursements. With cutting edge technology and deep industry knowledge, we have helped our clients minimize denial rates and maximize revenue in no time.

Ready to streamline your claims process? Discover how Uniserve RCM’s essential features can help you efficiently manage denials and rejections.