HMO

HMO is a term health maintainance organization which means group of doctors will participate in the group (HMO) to various service to patients.HMO require an authorization in order to see a specialist in case the PCP itself is not a specialist ,if PCP is itself specialist in the treatment no authorization needed.In emergency case also no need of authorization in HMO, the main moto of the HMO is to provide the cost effective and affordable service at right.Also HMO will have the periodic check up to prevent disease ,because periodic check up will allow a patient to find out how he was affected and according to that seviourity the treatment will be provided and cured...

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Insurance denial - INAPPROPRIATE BUNDLING OF SERVICES

"INAPPROPRIATE BUNDLING OF SERVICES" Description: This indicates a lack of awareness of the National Correct Coding Initiative Edits (NCCI) that govern appropriateness of tests being performed together on the same date of service. Alternately, it may indicate a lack of understanding of the appropriate code status of a specific CPT code. For example, payment for "B" status code services is always bundled into payment for other services, whereas with "C" status codes, the local carrier determines bundling and the appropriateness of the procedure and subsequent reimbursement.Action:Access the NCCI Edits on the Medicare Web site (http://www.cms.hhs.gov/NationalCorrectCodInitEd/) to review which codes can and cannot be billed together on the same date of service, as well as the appropriate...

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Insurance denial - Incorrect CARRIER

INCORRECT CARRIER Description: The claim was submitted to the incorrect payer/contractor for payment.Action:It's important to screen patients and be aware of the types of services provided prior to submitting a claim to the carrier. Check the patient's Medicare card and verify the Health Insurance Claim (HIC) number on the card. Patients with traditional Medicare coverage will have HICs of nine digits followed by an alphanumeric suffix. Patients who have railroad retirement (a type of federal health care coverage) will have HICs with an alpha prefix followed by either six or nine digits. Verify whether a Medicare-replacement Health Maintenance Organization (HMO) covers the patient. You can obtain this information by calling the Provider Service department, or online via your carrier's...

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Denial claim - MEDICARE IS THE SECONDARY PAYER

MEDICARE IS THE SECONDARY PAYER Description: The care of a Medicare patient may be covered by another payer through coordination of benefits. Medicare may be the secondary payer in our offices for the following reasons:* Working aged. The Medicare patient is: 65 years or older, employed full- or part-time by an employer who has 20 or more full- or part-time employees, and covered under the Employer's Group Health Plan (EGHP); or covered under the EGHP of an actively employed, full- or part-time spouse whose employer has 20 or more employees.Liability and auto/no-fault liability: Section 953 of the Omnibus Budget Reconciliation Act of 1980 was amended by the Deficit Reduction Act of 1994. It precludes Medicare payment for items or services to the extent that payment has been made...

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Medicare EOB - PR - 3 Co-payment Amount

PR - 3 Co-payment AmountDescription:Copayment A specified dollar amount or percentage of the charge identified that is paid by a beneficiary at the time of service to a health care plan, physician, hospital, or other provider of care for covered service provided to the beneficiary.Cost Sharing The general set of financial arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both. Cost sharing can also occur when an insured pays a portion of the monthly premium for heath care insurance.Action:1. We need to bill the patient.2. If there is any other insurance coverage if the patient has, we can bill to that insurance al...

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Adjustment code - CO and CR - What does it mean

Adjustment Group Code Glossary for "CR" CR - - Correction to or Reversal of a Prior DecisionA CR group code is used whenever there is a change to a previously adjudicated claim. CR explains the reason for the correction; PR, CO and/or OA must always be used in tandem with CR to show the revised information. Separate reason code entries must be used in the NSF for the CR group entry, and any other groups that apply to the readjudicated claim.What is explanation for denial adjustment group code of COCO - Contractual ObligationsA CO group code identifies amounts for which the provider is financially liable. These include, participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties, Gramm-Rudman reductions, or medical...

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Claim processed as PR - 2 Coinsurance Amount

PR -  2  Coinsurance AmountCoinsurance amounts are generally 20% of the Medicare fee schedule. Physicians must collect the unmet coinsurance from the beneficiary. Consistently waiving the coinsurance may be interpreted as program abuse. If a beneficiary is unable to pay the coinsurance, the physician should ask him or herto sign a waiver that explains the financial hardship. If no waiver is signed, the beneficiary ’ s medical record should reflect normal and reasonable attempts to collect, before the charge is written off.Action :  1. We need to file the claim to secondary insurance2. If there is no secondary insurance we can bill the patie...

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what is ANSI Group Codes

ANSI Group CodesAn ANSI Group Code is always shown with each ANSI reason code to indicate when you may or may not, bill a beneficiary for the non-paid balance of the services or equipment you furnished. Group codes are not used with Medicare Reference (REF) or Medicare Outpatient Adjudication (MOA) remark code entries.CO -  Contractual ObligationsPR -   Patient ResponsibilityOA -  Other AdjustmentCR -   Correction to or Reversal of a Prior DecisionPI - Provider initiated ref...

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Insurance denial - CO 39 Services denied at the time authorization/pre-certification was requested.

CO 39 Services denied at the time authorization/pre-certification was requested.AUTHORIZATION/REFERRAL PROBLEM    Action:  Some carriers insist on obtaining prior authorization from them before the surgery.  This may be for certain specific procedures or may even be for all procedures.  So these are carrier specific and procedure specific.  Please note that it is the responsibility of the Surgeon and not the patient to obtain the authorization# from the carrier.    When you get a denial from the carrier for this reason, first check the system to see if any note entry has been made for the patient for the dos concerned and for the procedure in question. Always read the entire notes since the claim might have already sent for reprocessing....

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Insurance claim processed as PR - 1 Deductible Amount

PR - 1 Deductible AmountDescripition:In insurance policy terms, a deductible is the amount of money which the insured party must pay before the insurance company's own coverage plan begins. In practical terms, insurance companies include a deductible in their policies to avoid paying out benefits on relatively small claims.Action : 1. We need to bill the patient.2.  If the patient has another insurance coverage which covers deductible we can file to that insurance, if the policy not cover primary deductibles we have no other way rather than billing the patie...

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What is PR and OA - denial EOB

What is explanation for denial adjustment group code "PR"  PR - Patient ResponsibilityA PR group code signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary’s behalf. For example, PR would be used with the reason code for patient deductible or coinsurance, if the patient assumed financial responsibility for a service not considered reasonable and necessary, for the cost of therapy or psychiatric services after the coverage limit had been reached, for a charge denied as result of the patient’s failure to supply primary payer or other information, or where a patient is responsible for payment of excess non-assigned physician charges. Charges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing...

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Insurance denial - CO 146 - Payment denied because the diagnosis was invalid

CO 146 - Payment denied because the diagnosis was invalid for the date(s) of service reported.Description:The following types of rejections are possible; Diagnose code does not match with the procedure code (check in LMRP). The Diagnose code reported on the claim is not to the highest level of specificity. Diagnose code is no longer valid.      Action: Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry, if yes, then correct it and resubmit the claim.  If no, it may be because of incorrect Diagnose code. It is possible that the 4 digit Diagnose code used is not the highest level of specificity and the carrier wants a five digit Diagnose code. Coders will also have to recheck to see if the diagnosis code...

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Insurance denial -CO- 182/CR - 182 Payment adjusted because the procedure modifier

CO- 182/CR - 182 Payment adjusted because the procedure modifier was invalid on the date of service.Definition :MODIFIER REQUIRED/INVALID MODIFIER Action:   First check whether modifier has been entered at the time of charge entry. If no, then resubmit the claim with the correct modifier. If modifier has been entered but the carrier rejects the same then check whether the correct modifier has been used. If you find that the correct modifier has been used, then call the insurance and find out the reason for rejection. Based on the feedback, take corrective action. One example, Blue choice (New York) rejected a lot of claims for the reason invalid or missing modifier. Carrier was called and it was found that they do not require modifiers hence forth and claims need to be billed...

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Insurance deny the claim - PROVIDER NUMBER IS MISSING OR INCOMPLETE

PROVIDER NUMBER IS MISSING OR INCOMPLETE Description: CMS1500 form Items/Box #24K and #33 are filled out incorrectly, with the UPIN (unique provider identification number) or information is missing, thus causing a denial of the claim.Action : For item 24K, enter the personal identification number (PIN) or national provider identifier (NPI) of the performing provider of service/supplier if you are a member of a group practice. When several different providers of service or suppliers within a group are billing on the same form CMS-1500, show the individual PIN or NPI in the corresponding line item.For item #33, enter the provider of service/supplier's billing name, address, ZIP code, and telephone number. These are required fields. Enter the PIN (or NPI when implemented), for...

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Denial claim reason - MISSING A MODIFIER OR HAS AN INCOMPLETE OR INVALID MODIFIER :

THE CLAIM IS MISSING A MODIFIER OR HAS AN INCOMPLETE OR INVALID MODIFIER :Description: The modifier necessary to process the claim correctly is either missing, incomplete, or invalid for the specific procedure and diagnosis indicated on the claim form.Action:Know the proper use of the CPT modifiers that exist and are appropriate to use for the specific condition or situation. The CPT modifiers are listed in their entirety in Appendix A of the current version of the CPT Manual. You can obtain the CPT manual from the American Optometric Association or from the American Medical Association. You should also know that misuse and abuse of modifiers are under the scrutiny of the Office of Inspector General (OIG) and that can result in significant penalti...

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Insurance denial - IMPROPER DIAGNOSIS or INCORRECT DIAGNOSIS

IMPROPER DIAGNOSIS or INCORRECT DIAGNOSISDescription:Services were denied because the diagnosis listed as primary was not a covered diagnosis for the procedures performed.ACTION:Check your specific carrier's local coverage determination (LCD) policy for the specified procedure to obtain a list of covered diagnoses, generally found on their Web site, or accessible on Medicare's Web site. Also familiarize yourself with the appropriate policies for medical necessity and documentation requirements. Be cautious of automated programs/software that provide a covered diagnosis for any given procedure. Keep in mind that having a covered diagnosis does not mean you can automatically perform any procedure for which the covered diagnosis exists. You must prove and document the reason in the medical record...

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Eligibility related denial claim

Denial - BENEFICIARY ELIGIBILITY Description: You submit a claim for processing and the beneficiary/patient does not have Medicare eligibility. Claims are often denied for eligibility for the following reason:* The beneficiary Medicare number is invalid on the claim.* The beneficiary is not eligible to receive Medicare benefits.* The beneficiary's claims must be filed to another insurance plan.Action :Screen your patients. Verify the Medicare number on the patient's Medicare card and file the claim exactly as it is printed on the card. Verify the patient's effective date for Medicare Part B from their Medicare card. Medicare cannot pay for services prior to the patient's effective date and will not pay for services if the patient has terminated his Medicare benefits. Beneficiaries...

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Dispute insurance denial - How to write appeal

How to Write an AppealYou may find that an effective appeal letter will often be all that is needed to reverse a claim denial or underpayment. Prior to writing an appeal letter, make sure you examine the EOB, also known as the Remittance Advice Notice, and the initial claim in detail.The Appeal LetterBe sure to reference all key elements in your letter and include documentation supporting your appeal as attachments. Documentation might include the following: approved prescribing information (PI), copies of the EOB or remittance notice in question, articles from peer-reviewed medical journals,relevant peer-reviewed literature, payer coverage policies, fee schedules, medical records, nurses’ notes, plan of treatment, consultation reports, and/or progress notes.Make certain that the claim is...

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What is clean claim

A “clean” claim is defined as a one that does not require the payer to investigate or develop on a prepayment basis. Clean claims must be filed in the timely filing period.Most payers consider clean claims as:◆ Claims that pass all edits◆ Claims that do not require external development (i.e., are investigated within the claims, medical review, or payment office even if the investigator does not need to contact the provider, the beneficiary, or other outside source)◆ Claims not approved for payment by the common working file (CWF) within seven days of the original claim submittal for reasons beyond the carrier’s or provider’s control (e.g., CWF system/communication difficulties) (Medicare only)◆ Claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the...

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Dispute insurance denial - Types of hospital Denials

Insurance claim denials generally fall into 2 major categories: claim-level denials and service-level denials. Medicare and Medicaid have created a set of status codes to indicate why claims have been denied. Appropriate hospital staff members involved in billing and coding should be familiar with thesecodes and what they mean to the organization. Code information can be found at the CMS Web site: www.cms.hhs.gov/manuals/IOM/list.asp.Denial of the entire claim is considered a claim-level denial. For many hospitals, this type of problem accounts for the majority of Medicare and Medicaid denials and typically results from inaccuracies related to patient registration, late-charge management, duplicate billing, production of medicalinformation for external review, and/or physicians’ ordering practices....

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Hospital Denials - review

Today, as hospitals face tremendous reimbursement challenges, many facilities are adopting bestpractices in denials management. This approach helps to recapture the full value of the services theyprovide to patients.Most hospitals recognize that resubmitting a claim does not solve their claims denial problems and areseeking to quantify the issue to improve overall claim payments. With this goal in mind, more and morehospitals are forming denial recovery units, maintaining denials databases for tracking and trendingpurposes, automating where possible, and centralizing operations to increase efficiency and decreaseerror rates.The Medicare Hospital Outpatient Prospective Payment System (PPS) created under the Balanced BudgetAct of 1997 has increased pressure on hospitals to bill accurately for...

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Avoiding denial - claim review before submission

Common Problems and SolutionsWhen a denial or underpayment is received from a payer, it’s often necessary to review the original claimsubmitted to the payer along with the EOB to identify and correct the problem. By doing this type ofanalysis, you can determine if there was a simple coding error or if the denial was based uponsomething else, such as the payer’s coverage policy on a specific procedure or product. Here are someitems to keep in mind when reviewing the original claim and EOB.1. Original Claim Analysis> Review the claim to ensure that all codes are complete and accurate—ICD-9-CM codes are listed and coded to the highest level of specificity(don’t use a truncated ICD-9-CM code when a more specific code is available)—ICD-9-CM codes are linked to each service line on the claim...

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Insurance claims recovery process

Claims RecoveryA claims recovery process is essential and should incorporate all traditional processes to recover the denied payment, including informal reviews, fair hearings, administrative law judge hearings, appeal council hearings, and federal district court hearings. All levels of appeal have specific timelines,document requirements, and dollar limits. A cost-benefit analysis should be used to determine the level of resources needed to pursue the denied claim. Use the following tips to assist each facility with claims recovery:> Establish a department coordinator to direct all communications regarding claims recovery. This team member will ensure an efficient and timely appeal process> Understand and meet all payer requirements for information submission. Failure to meet these...

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How to success in denial management

Claims Denial ManagementClaims may be denied or underpaid for a variety of reasons.Common reasons for denial or underpayment may include the following:> Clerical errors, such as misspellings and transposed numbers> Questions about medical necessity> Improper use of diagnosis codes> Incorrect procedure codes and/or modifiers> Missing information> Incorrect billing unitsInsurance payers typically have a formal process that permits providers to appeal denied claims or inadequate reimbursement for drugs and/or services. If your claim is denied, you will receive an EOB from your local insurance claims processor explaining the reason(s) for noncoverage. You may resubmit the claim, requesting a redetermination of coverage. A well-written appeal letter can be very effective...

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How to review EOB - AR specialist

Explanation of Benefit (or Remittance Notice) Analysis> Determine why the claim was denied by analyzing the denial codes, which are usually on the bottom or back of the EOB> Cross-reference actual reimbursement from the payer to their allowables to determine if the claim was underpaid, paid correctly, or overpaid. Allowables are often published in provider bulletins or in your contract with the payer> If the payer has changed any of your codes, you may want to go back and review how you’re using those codes and whether they are being used appropriately> Take care to file appeals within the time constraints of the payer (for Medicare, the limit for appeals is 120 days from the date of initial denial); keep in mind that a payer may require a specific appeal form to be submit...

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Denial EOB example

 Here is the image for denial EOB from Medicare insuran...

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Top Five DME MAC Claim Denials for Podiatry Specialty

The top five denials below are for the period of October 2008 through December 2008. These claims wereidentified from Specialty 48, which represents Podiatrists. The denials identified are for all of DMEMAC Jurisdiction A SuppliersTop FiveClaim Denials     # of Denied Claims     Reason For Denial      CO 96, N115                                       2,371     This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. Non-covered charge(s)   CO 18, N111                  ...

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When we need to appal and how to appeal the claims

The Appeals ProcessWhen an insurer denies or underpays a claim, first examine the original claim and the Explanation ofBenefits (EOB) to determine whether there is inaccurate or insufficient information. Claims denied forthese reasons can simply be resubmitted with the corrected or additional data required.Should a payer deny a claim for some other reason, consider filing an appeal. Industry sources indicatethat only 10% of claims are appealed, but that 90% of appeals are successful. In fact, according to anOffice of the Inspector General report, there has been an increase in appeals to Medicare at theAdministrative Law Judge (ALJ) level (99% increase); in these appeals, 81% of the initial denialswere overturned.By law, all payers must have a procedure for filing appeals. Below is the process...

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Filing adjustment form of Medicare Tips for Filing Adjustments

The following tips will assist in completing the adjustment form• Complete only one adjustment request form per claim; a separate adjustment request form for each line item on a single claim is not necessary.• Reference only one ICN per adjustment request form.• If requesting a review of a previously denied adjustment, reference the original ICN and resubmit with all supporting documentation related to the adjustment. Do not reference the ICN for the denied adjustment.• Include a copy of the appropriate RA with each adjustment request. If multiple RAs were involved in the claim payment process, include copies of each RA.• Include a copy of the claim that is referenced on the adjustment request.Note: This is not required for electronically submitted claims.• When the adjustment request involves...

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most common mistakes - Filing adjustment form

The most common mistakes that are made when filing adjustments are these:• Incomplete or invalid MID information or ICNs• Multiple ICNs on the same form• Unspecified or too-general reason for the adjustment request• Missing copy of the RA related to the request• Missing reference to the original ICN, or use of a denied adjustment ICN• A partial payment or partial recoupment number is not referenced as the original ICN• Filing the adjustment after the 18-month time limitNote: If an adjustment is not filed until the 17th month from the date of service, the original claim may no longer be available in the system for adjustment. Submit adjustments as soon as possible so they can be processed within the 18-month time limit.• Missing required documentation (Medicare vouchers, medical records, operative...

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Common Insurance denial reason

Some of the Common Insurance DenialsClaim denied for Missing / Additional informationClaim denied as DuplicateClaim denied for Prior-Authorization / Referral:Claim Denied as InclusiveClaim denied as included in Global periodClaim denied as not medically necessary / Pended for medical notesClaim denied as non covered serviceClaim denied for eligibilityClaim denied for late filingClaim denied as CPT - Dx mismatchClaim denied / Pending for accident information: (Workmen's Compensati...

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Three key fundamentals to effective denial management

The three key fundamentals to effective denial management.PreventionPrevention focuses on actions that can be taken upstream in the patient encounter to prevent denials from occurring in the first place. Prevention can be introduced anywhere in the patient encounter such as: Pre-admit/Pre-registration, Scheduling, Admit/Registration and Billing. Our denial management experts ensure that we track such trends and keep the Client informed periodically about improvements/process changes that can be made across functions.AnalysisThe process of analyzing and aggregating similar denials is strategic in denial management. The Denial management team understands that analysis and segregation is a forerunner to follow-up process and hence for us it is an fundamental step in denial management.Tracking...

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What is denial managment soloution

Denial Management Solution A good denial management process is not simply about working denials, it is about systematically gathering the data required to eliminate denials. Working denials is like pumping water from your basement when a pipe bursts. Denial management is about fixing the pipe so you no longer need to pump water from the basement.We also understand that achieving powerful results from denial management requires data, data and more data. Our denial management process reports and measures all claims that are being denied by your payers. With this level of data our Denial Management specialists can fix the issues that are leading to the denials (whether it be issues with the claims or issues with the payers) and stop the torrent of unpaid claims into your medical billing...

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Claim denied as - inclusive, maximum per unit, injury liablity and pre existing

Claim denials for maximum unites per visit Check your units of the CPTClaim denied as inclusive with the primary procedure Some service covered with primary procedure, Hence we needs to taken write off the claim balance after primary CPT paid. However there is chance with resubmit the inclusive procedure with modifier.Claim denied as services not provided or authorized by designated File the claim along with appropriate authorization#. If we don’t have authorization# sometimes we can appeal the claim along with necessary medical document.Claim denied because of incorrect medical coding Should be file the claim with correct diagnosis (Dx) and CPTClaim denied because this injury is the liability of the no-fault carrier. Should be file the claim to patient auto-insurance.Claim...

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Type of denial - difference between rejection and denial

Claim denial typesThere is no particular type in denial however below are the common reasonClaim might be denied for incorrect coding information.Claim might be denied for incorrect provider information.Claim might be denied for incorrect coverage informationClaim might be denied for lack of informationClaim denials by managed care organization plague long-term care providers Should be file the claim to patient HMO planClaim denied for coordination of benefits Patient needs to update the COB information to insurance. If patient has more than one insurance, patient need to call the insurance and inform that which insurance is primary and secondary for patient. Patient only can update the COB information to insurance.Claim denied for maximum benefits reached File the claim to...

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Denial managment process

Denial ManagementDenial Management is a new process methodology whereby patterns and consistencies within denied transactions are analyzed and resolved in a batch process regardless of the account. For example, United Healthcare is denying all supply charges for knee arthroscopies as bundled for our Dr. Smith at his primary location. A denial management methodology will provide all open balances (balances not equal to zero) of accounts receivable that meet these conditions. The billing staff will analyze and resolve these conditions in one action based on a denial reason rather than account by account within a certain queue.StrengthsProvides a reporting vehicle to reduce incoming denials within the provider RCM processAllows capture of the consistency in transaction denials by provider, payer,...

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Account receivable managment - what is task management

Task ManagementTask Management is embedded within the majority of commercial practice management or receivable management systems. This methodology lifts or queues accounts within the existing accounts receivable based upon some user defined rules in order to serve up an account to be worked. For example, all surgeries for a particular physician—let’s say “Dr. Smith”—greater than 60 days old would be a task queue or segmentation of accounts to be worked. This technology is a great improvement over working a simple accounts receivable aging from highest to lowest dollar, whereby the bottom half of the list never gets touched due to the size and scope of the entire list.StrengthsAchieves a segmentation of the A/R to allocate among the billing staffProvides the billing manager with some basis...

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Task Management versus Denial Management

Accounts Receivable Management: Task Management versus Denial ManagementThe process of medical accounts receivable (A/R) management is truly a misnomer. In a perfect world, accounts receivable would require nothing more than collection—not management or process. However with growing complexity, payment ambiguity, payer plans, co-pays, co-insurance and other factors that drive up costs in healthcare delivery, the management of the accounts receivable process continues to demand more attention. With an average of 30 percent in denial rates and informed speculation of 15 percent in lost revenues on an annual basis, we must conclude that the management processes currently in place are woefully inadequate and costly. Unfortunately, the national healthcare debate on improvement does not address...

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Key Functions of Denial Management

Maximize cash flow - Reporting identifies denial causes having the greatest financial impact, thereby accelerating cash flow.Identify the root cause of denials - Collecting and interpreting denial patterns to quantify denial causes and their financial impact.Support accurate workflow priorities and scheduling for follow up - Collecting information on denial appeals, including status, escalation, correspondence with payers, and the disposition of denial appeals to increase recovery amounts.Provide accurate and timely statistics for Management / Clients - Providing management analysis reports and other information to prevent future denials.Track, Prioritize & Appeal denials - Generating appeal letters based on federal and state statutes and case citations favoring the medical provider's...

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