Protocols for Managing Claim Denials

For many independent healthcare providers, claim denial is part of the business and occurs frequently. On average, the claim denial rate in the healthcare industry is between 5 and 10 percent of all claims filed. Only a few billing partners can boast of a near-zero claim denial record. More importantly, only a handful has a flexible protocol designed to handle claim denials.

To maximize your revenue and achieve your financial projections, your billing partner must adopt an effective protocol in this regard. The first step to designing a system for managing claim denial is to understand the most common billing mistake leading to claim denials (embed a link to the second blog here). At XyberMed, we have researched the most effective protocols to minimize claim denials in a bit to optimize your earnings.

  1. Collate Data on the Current State of Denials

What are the most common reasons for denials? Collating the denial data from Payors helps you monitor why most of your claims were denied in the first place. The most frequent reasons under this category include duplicate billing, wrong coding, wrong filing, and expired insurance eligibility. Identifying the most common reason in your practice helps you structure an effective management plan to correct these errors.

  • Create a Workflow for Denial Reporting and Appeals

How should denials be immediately treated? Creating a standard workflow for reporting claim denials. Your workflow should list a stepwise approach for reporting denials, checking for errors, and filing an appeal. This approach provides an action plan mandating employees to create a manual record of denial management and attend to the clients’ inconvenience. Also, medical billing companies using a digital network for denial management are more efficient with this.

  • File Appeal Applications Within a Week

Submitting an appeal swiftly after correcting a billing error is important in denials management. Quick appeals work better for providers with a short claim-submittal time. However, appeals must be carefully modified and properly filed to prevent another denial. Most importantly, your workflow protocol should be fast enough to process an appeal within a week after a denial is recorded. Insurance providers have different guidelines on appeal submission; understanding these guidelines also helps your management process.

  • Track Appeal Submissions

Yes. You should follow your appeal through the system to ensure they are swiftly processed. For Medicare providers, appeals submitted after the clam-submittal period are invalidated. Commercial providers also have strict guidelines on appeal submissions. Tracking the appeals through the systems eliminates the possibilities of technical error or human error in filing, indexing, and resubmission.

  • Monitor Progress and Report Outcome

While tracking the appeal, be sure to monitor the progress level and report to the workflow. In case formal modifications are needed in the appeal, getting a legal team involved might be helpful. An appeal letter can also be written to document the clients’ experience and include clinical logic supporting any additional or previously rejected bill item on the claim. Documenting your outcome is important for optimizing the denial management workflow.

Bill automation using innovative technology in medical billing help reduce the error denial rate for independent practitioners. This is why the XyberMed Front Desk Solutions are designed to properly handle medical billing and coding for independent healthcare providers across the globe. 

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