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From the Editor’s Desk

        What happens to denials?

        Insurance denials represent the last hurdle to overcome   MANAGE a well-defined denial workflow process efficiently.
        in the revenue cycle journey to the reimbursement finish
        line.  Denied claims represent delayed or lost revenue for   •   Don’t delay after you identify the denial.  Start working
        organizations.  Addressing the underlying cause of           on the resolution.
        problems minimizes denials.                             •   Don’t rebill for the sake of re-billing.  Focus on resolving
                                                                     the denial.  Creating duplicate claims will only
        Despite your best efforts, you will still encounter an        compound the problem.
        occasional triggered denial that blocks your path to    •   Choose when to stand your ground.  Battling over timely
        reimbursement.  All too often, it seems that investigative skills        filing of claims that are dead-on-arrival to the payer is
        rivaling those of the world’s greatest detective are required        a vexing exercise.
        to provide answers based on limited feedback from the   •   Build your case by following payers’ guidelines for
        payer’s remittance—frequently part science / part art.       re-submission.  Consider this your “blueprint”
                                                                     for reconsideration.
        Best practice dictates following a four-step process
        to IDENTIFY, MANAGE, MONITOR, and PREVENT denials.      •   Construct a letter that builds your case with
                                                                     supporting documentation.  If the denial is unreasonable,
                                                                     look for similar denial patterns on other insurance claims
                                                                     and gather enough evidence to launch a group appeal.
                                                                •   Be mindful of certain contractual adjustments.
                                                                     Scrutinize those adjustments before accepting them
                                                                     at face value.

                                                                MONITOR an effective denial management program.
                                                                It is more than just the assignment of the employee to
                                                                the type of denial.
                                                                •   Observe the denial reason, frequency, payer, and the
                                                                     employee’s methodology and productivity.
                                                                •   Audit the work of employees.
                                                                •   Evaluate the steps of the appeal process and the
                                                                     timeliness of the appeal.
                                                                •   Develop techniques to build an appeal case to the payer
                                                                     and hold staff accountable for the quality of work and
                                                                     the outcomes.
        IDENTIFY the type of denial by grouping claims into
        categories to analyze patterns.  Reason and remark codes   PREVENT denials from becoming a recurring “crime screen.”
        provided by payers require you to decipher and interpret.   Profile your payers and look for suspicious behavior that
                                                                impacts your revenue cycle, and don’t forget to minimize
        A common denial, “CLAIM/SERVICE LACKS THE               denials that are self-inflicted.
        you to wonder what the payer means.  Denial descriptions   The foundation for a denial prevention program is grounded
        like this would be akin to a weather forecaster calling for   in the forensic interpretation of denial data.  Analytical tools
        “AMBIGUOUS” WITH A CHANCE OF “OBSCURE.”                 available on the market today produce root-cause reporting
        No one would accept that forecast, and you should       and enable you to be proactive instead of reactive.
        never accept an ambiguous or obscure denial.

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