From Denial to Approval: Proven Strategies to Combat Claim Denials and Boost Revenue

Denials are an often undermanaged area of revenue cycle management. Not having a proven strategy for mitigating denials simply causes more denials. There is the potential to experience write-offs and lost revenue when denials are not a focus. This webinar lays out practical processes for dealing with and resolving denials, timely and efficiently to capture the revenue you work so hard to earn. Participants will be able to self-report they can identify one successful strategy to consider when writing healthcare related appeals and one common mistake to avoid when writing healthcare related appeals.

Learning Outcomes:

• Discuss best approaches to resolving denials
• Understand the difference between a common and a complex denial
• Discussion of contractual and non-contractual adjustments
• Best practice for keeping aged accounts receivable in an acceptable range
• Calculating your denial rate
• How to identify specific denials
• Steps for denial prevention
• Determining root cause analysis for denials
• Strategies for resolving denials
• Handling appeals when needed

Areas Covered in the Session:

• Definition of a Denial
• Interesting Facts About Denials
• Why are Managing Denials So Hard?
• Steps for Denial Prevention
  • Develop a Denial Culture
    • Stress a culture of denial prevention
    • Assemble your denial prevention team
    • Have each team member assess skill sets of staff – identify gaps
  • Denial Rate Calculation
    • Calculate your denial rate
    • Calculate this percentage by:
      • Practice as a whole
      • By Payer
      • By Specialty
      • Location if you have more than one office
  • Identify Specific Denials
    • Identify the reasons for denials and categorize them into main “buckets”
      • Registration errors
      • Charge entry errors
      • Referrals and pre-authorizations
      • Information needed from the patient
      • Duplicate claims
      • Medical necessity
      • Documentation errors
      • Bundled/ non-covered services
      • Credentialing issues
      • Other
  • Identifying Denials
    • CARC (Claim adjustment Reason Codes)
    • RARC (Remittance Advice Remark Codes)
  • Divide by Category
  • Root Cause Analysis
  • Resolve the Denials
    • Assign appropriate staff and by staff expertise to denial resolution
    • Registration Denials- A Common Denial
    • Duplicate Claims: Sometimes there are special circumstances causing duplicate claims
    • Claim lacks information needed for adjudication
    • Lacks Medical Necessity: Refer to payer policies to help resolve the denial
    • Coding related: Some coding denials are common like global, modifiers, units and bundling
    • Referrals and authorizations: Make sure the practice is up to date on all payers requirements for referrals and pre-authorizations
    • Credentialing: Review the status of the application with the payer and Figure out how to bill for a provider while waiting credentialing status
• Tips for Denial Management
  • Know your payers reimbursement policies
  • Develop “experts” among your denial management/billing staff
  • Experts for each major payer
  • Optimize claim management using claims management software
  • Educate payment posters about appropriate write-offs
  • When all else fails: Appeal the claims
  • Each third-party payer has their own process for appealing claims
  • Appeal Process – there is a right way and a wrong way to appeal
  • When to escalate denials or other payer issues
  • Sometimes payers appeals process is not effective
• Managing Aged Accounts Receivable
• General Benchmarks for A/R
• Calculate the Cost of Re-Work
• Cost of Rework Example – Lost Revenue
• Best Practice Denial Management

Recommended participants:

• Healthcare Administrators
• Physicians and Nurses
• Non-Physician Practitioners
• Medical Coders
• Medical Billers
• Medical Auditors
• A/R Staff
• Revenue Cycle Staff
• Claim Handling Specialists
• Medical Officers
• Practice Managers
• Compliance Officers
• Hospital and Medical Staff
• Anyone Who Want to Learn About Handling Denial and Appeal Process

Presenter Biography: