Denial managment process

Denial Management

Denial 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.

Strengths

• Provides a reporting vehicle to reduce incoming denials within the provider RCM process

• Allows capture of the consistency in transaction denials by provider, payer, procedure, date

and reason

• Improves claim throughput per FTE by three to four times

• Segments claims production issues from A/R issues

• Bypasses embedded, queue-based rules in practice management systems to eliminate

duplication and provide the ability to pull all receivables with all balances for analysis

• Allows view of credit balances within a provider or practice

• Allows for development and implementation of denial adjudication rules to manage

certain conditions

• Easier process to train new staff

• Derives A/R independently from embedded practice management applications

Weaknesses

• Requires integrated payment posting and imaging and indexing of correspondence to fully

optimize the process


Denial Management

Denial Management isolates and eliminates the traditional excuses in accounts receivable for healthcare by forcing action to resolve accounts versus just working accounts. Clear, definable accountability from the denial management process is a critical benefit in addition to the other benefits.

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