Denial Management Archives - InfoHub Tue, 15 Nov 2022 09:08:14 +0000 en-US hourly 1 Denial Management Archives - InfoHub 32 32 A Guide for Comprehensive ” DENIAL MANAGEMENT” Tue, 15 Nov 2022 09:00:40 +0000 Denial Management, in simple words, is a strategic process that resolves any issues which might cause claim denials. Both rejected claims and denied claims have the potential to be a huge issue for healthcare organizations. Denial management is considered one of the most complicated yet vital parts of the revenue cycle management process. Seeking professional help from a medical billing company with the right tools is considered the most convenient solution here.
As denied and rejected claims have a direct impact on the revenue cycle, it is important to get it right. It is advisable to employ a system monitoring the denials and what causes them. This is one of the most important steps to take into consideration before you try and look for solutions. So here is a comprehensive guide for the Denial management process.

There are two types of Denials

  1. Hard Denial – A hard denial is permanent, and cannot be corrected or reversed. Hence the revenue over which is considered to be lost.
  2. Soft Denial – A soft denial is temporary, and is payable if the necessary information is added or rectified.

Claim Denial can be a result of many issues.

Here are the top five to keep an eye out for:

  1. Duplicate Claims – This situation arises when a claim is submitted for a single encounter on the same day for the same patient by the same provider for the same service team.
  2. Incorrect or Missing Information – This covers anything from a missing field or blank field to coding errors.
  3. Prior Authorization – Before service is performed if prior authorization is not being taken then the claim can be denied.
  4. Benefit Coordination – Patients who are covered by more than one health plan can lead to delays or denials of claims. This can be avoided if the patient’s benefits are coordinated.
  5. Network Provider – If the services are provided by an out-of-network provider can lead to the payer denying to pay the claim or a part of it.
  6. Deadline Exceeded – When the payer’s required days of service are exceeded it can lead to delays in claims.

Once you have correctly located the causes for denials, here comes a tougher task. Denial management and making sure that it does not occur frequently is a meticulous procedure.

Here are a few things to keep in mind to make this process easier:

  1. Common Reasons – Denials or delays in claims can occur due to various reasons. It primarily depends on the type of healthcare organization and the scale on which they function. If there are any repetitive errors occurring then specific changes along those lines need to be made.
  2. Quick Assessment and Action – In case any denials take place or if there are any delays then it is important to follow up and get them corrected. The preferred time limit for this is within a week.
  3. Clear Delegation of Jobs – Managing the denials procedure is a tedious process. It consists of a lot of steps and they need to be error-free for a seamless workflow. If the work is delegated amongst different departments or outsourced to medical billing agency or a medical billing company can assure error-free and hassle-free work.
  4. Establish A Work Model – In any healthcare organization denials are an integral part of the revenue cycle. An effective work model in place can help you handle this issue in a much better manner.

Keep The Process Organized – An organized denial management process can facilitate solutions to resolve any delays or denials in claims. Denied or delayed claims can lead to a reduction in revenue and some grave administrative issues.

Financial stability is vital for any healthcare organization. A sustainable Denial Management process can help streamline the process while weeding out any causes leading to denial or delays. A simple solution could be to outsource medical billing services to a medical billing agency.

We, at Info Hub, provide the best-in-market medical billing services equipped with an experienced and skilled team to turn denials into revenue.

How to Create an Effective Denial Management Strategy Thu, 28 Apr 2022 11:21:45 +0000 Medical claims are an important aspect of your practice’s revenue. When claims are refused, it can be a significant source of financial loss. Denied claims not only increase days of the revenue cycle, disrupting cash flow, but they can also cost you money if not resolved quickly. The cost of processing each refused claim further adds to the strain. Are you experiencing high denials, and looking for a sound strategy to manage these denials? It is important you understand why your claims are being denied, based on which you can devise a strategy to reduce further denials and keep your practice from losing revenue.

Types of Denials

  • Soft Denials – A soft denial is only meant to be temporary. If the claim is amended and/or further information is added, it may be paid.
  • Hard Denials – It is irreversible. It is revenue that has been lost since it cannot be rectified or restored.

Reasons Why Claims Get Denied

Identifying the cause for the denial is the very first step in an effective denial management strategy. When evaluated claims are sent unpaid, the insurer will usually explain why on the accompanying payment explanation. It’s vital to remember that the majority of people are unaware of the insurance denial process. It is your front office staff’s responsibility to emphasise the need of precise documentation and insurance information.

  1. Service previously settled
  2. Service unqualified under a healthcare plan
  3. Missed deadline
  4. Incorrect/missing information
  5. Duplicate claims

The following pointers form the basis for an effective denial management strategy

  1. Identify – Find and fix the problems that lead to claims being denied by insurers.
  2. Manage – Categorize denials according to their reason, source, cause, and other distinctive characteristics.
  3. Monitor – Keep track of denials, audit employees’ efforts, and give the tools, technology, and resources needed to get the job done.
  4. Prevent – Work with patients, recommending physicians, and others to appeal and overturn unjustified denials.

Read on to know more about how to go about developing an effective denial management strategy.

Re-submit Claims in the Stipulated Period

Follow your rejection management guide, evaluate the insurer’s associated denial communication, and double-check your internal documents. If necessary, contact the patient. Remember that most insurers have time constraints on resubmitting claims; the last thing you want is to be denied reimbursement because of a late submission.

Examine the Denials

The easiest method to deal with claim denial is to prevent it from occurring in the first place. According to industry sources, the typical denial rate for practices is between 7 and 10%, whereas there should be no more than 4% and no more than 2%. Preventive denial assessment is a root cause analysis of all denials received with the goal of lowering the denial rate in the future. Here are a few things you may to want to analyze –

  1. What was the source of the denial? Was it a billing error, a coding issue, patient eligibility, the wrong payer was invoiced, or anything else?
  2. Is it possible that this denial might have been avoided? The solution to this question will astound you.
  3. What could have been done to prevent the denial? Review your eligibility verification procedure to see if it needs to be fine-tuned if it was an eligibility issue.
  4. Perform an 80:20 analysis of your denials to determine which issues are the most bothersome and how they might be rectified.
  5. Don’t try to change all of your processes at once; taking it one step at a time will yield better outcomes.

Watch For Trends and Patterns

Denials frequently share at least a few common characteristics. Regular analysis aids in determining these trends and identifying causes, allowing you to better plan to fend off income threats.

Organize the Process

The denial management procedure should begin as soon as a denial is discovered. This entails the steps below.

  1. Directly route denials to the affected individual’s work list. A coding error, for example, must be reported immediately to the coder.
  2. Sort the assignments on the denial work list by cause, time, and cash amount
  3. Remember to act quickly to avoid automatic re-billing and to strengthen your case.
  4. Create a denial management manual for your workers and create a uniform methodology for each major type of denial.

Denial management is a continuous effort for all healthcare facilities, and it takes up a lot of staff time. You can lower your denied claims by offshoring your denial management process to a revenue cycle management business. Info Hub provides custom-tailored systems and reporting tools for each client. To help you enhance your bottom line, we offer the full range of revenue cycle management services.

We work with you at Info Hub, an offshore medical billing firm, to reduce denials and underpayments, manage claims, improve patient eligibility verification and payment collections, and reduce compliance concerns and risk. Contact us to improve the efficiency of your daily revenue cycle and business processes.

Medical Claim Denials and Rejections in Medical Billing Tue, 26 Apr 2022 09:35:19 +0000 Filing healthcare claims is a complicated and an ever-changing process, as innovation and regulatory requirements can sometimes seem daunting. Mastering claims processing is an on-going skill, but understanding the basics is the first step to accomplishing this world. Knowing the distinction between rejected and denied claims is one of the keys! One of the most significant roadblocks to healthcare reimbursement is insurance claim denials and rejections. In the billing sector, the phrases “claim rejection” and “claim denial” are frequently interchanged.

This misperception can result in expensive mistakes and have substantial impact on your revenue cycle overall. For timely cash flow, proper knowledge and administration of accounts receivable and process are required.

What is Claims Rejections?

Claims rejections are those claims that are rejected by insurance companies because they do not fulfil particular data standards or basic formatting guidelines established by the Centers for Medicare and Medicaid Services.

The insurance companies are unable to process these rejected medical claims since they were never received and recorded into their systems. The claims cannot be processed if the payer has not received them. Once the inaccuracies have been addressed, the claim can be resubmitted. These mistakes can be as basic as a misplaced digit in the patient’s insurance ID number, and they are usually easy to fix.

What is A Denied Claim?

Medical claims that have been accepted and processed by the payer but have been categorised as unpayable are known as denied claims. These “unpayable” claims usually have an error or a lack of previous authorization that was discovered post the processing of the claim. Missing information, non-covered services per plan, and even procedures that are not medically essential, are some of the reasons for denials. Although it may appear that resubmitting the claim for a second review is simple, a denied claim cannot be resubmitted. It’s important to figure out the reason why the claim was initially denied.

Denied claims can usually be rectified, appealed, and returned to the payer for processing. To get to the root of the problem, however, this method can be time-consuming, costly, and resource-intensive. If a denied claim is refiled without an appeal or reconsideration request, it will almost certainly be taken as a duplicate claim and denied again. If this occurs, the claim will go underpaid, which can have a significant impact on a provider’s practice, especially if it is a reoccurring problem. When resubmitting denied claims, time is also a consideration. Each payer gives you a specific duration to submit a corrected claim. If the deadline is not reached, the payer may refuse the claim for failure to file on time. As a result, there is an outstanding claim that becomes the responsibility of the supplier.

The purpose of the medical biller is to ensure that the provider is paid for their services. Human and electronic faults are, unfortunately, unavoidable. Because medical billing involves both health and money, it’s critical to eliminate as these mistakes as soon as possible. When an insurance provider denies a claim, a record of the denial is kept in their system. If they reject a claim, they do not maintain a record of it in their system.

Do you get stressed out by the burden of claim follow-up and accounts receivable management? It’s a lot easier to navigate the medical billing procedure when you know the difference between rejection and denial. Let the professionals at Info Hub, an offshore medical billing company, to aid you with your billing needs. On a daily basis, our knowledgeable staff follows best practice payer-specific policies and protocols to assure that your claims are neither rejected nor denied, and that they are paid appropriately and on time.

Importance Of A/R Follow-Up And Denial Management Wed, 16 Mar 2022 12:31:12 +0000 Accounts Receivables that are way overdue should be followed up on promptly, along with effective denial management that contributes to the health of a healthcare providers financial strength. The primary purpose of accounts receivable management in healthcare is to increase cash flow in a practice by shortening the collection duration and lowering the associated costs. Is your practice looking for ways to get paid for pending claims, or reopen rejected claims? A dedicated A/R follow-up team can help you with the same.

What is Accounts Receivable?

Money that is due to physician businesses for medical care delivered to patients is referred to as Accounts Receivable (AR). Any payments pending from insurance companies, patients, or other guarantors are included in the accounts receivable process. AR management includes re-filing rectified claims, detecting denied/unpaid claims, minimizing AR days, and removing old account receivables.

Accounts Receivable and Denial Management

Physicians, hospitals, and nursing homes provide an ever-increasing number of services. Patients owe a certain sum to the physicians or hospitals every time they receive treatment and care. A good insurance model aids healthcare organisations in quickly and easily recovering overdue payments from insurance companies. Accounts receivable (A/R) and denial management are necessary in this situation. It enables healthcare service providers to conduct their businesses smoothly and successfully while also ensuring that money is reimbursed sooner.

Understanding the Importance of A/R Follow Up

A medical organization’s accounts receivable follow-up team is in charge of investigating rejected claims and reviewing them in order to collect maximum compensation from health insurers. Medical billing, accounts receivable, and revenue cycle management are handled by billing experts with certain skill sets. A medical billing professional determines the exact procedure code and diagnostic code depending on the treatment plan during other processes in medical billing. In case of errors in adhering to guidelines, claims may be refused; therefore, it is critical to have a dedicated A/R team that can follow up with the insurance providers to address disputed claims.

A/R follow-up management is critical for most firms in the medical billing process. Here are a few of the more common reasons why A/R follow-up is crucial:

  1. Quick Payment of Outstanding Amounts – The primary goal of A/R management is to reduce the amount of time that accounts are permitted to be overdue. The team keeps track of accounts that haven’t been paid, determines the best course of action for securing payment, and executes payments.
  2. Maintaining the Financial Health – Ensuring a positive cash flow is critical to any healthcare service provider’s financial viability. The A/R department takes care to see that the hospital maintains a consistent flow of money in order to cover expenses and provide patient care services.
  3. No Missing Claims – The most common cause of payment delays is the failure to receive a claim. This typically occurs when paper claims are misplaced. It is preferable to send claims in electronic format to avoid this. If you’ve followed up on the claim and know it hasn’t been received, it’ll be much easier to send another request for the claim soon.
  4. Recover Pending Claims – Due to additional information needed for the member, claims are sometimes left pending for a period of time. By appropriately following up, the A/R team can tell the member about the situation, and then take appropriate measures to expedite the process.
  5. Recovery of Unpaid Payments – A/R follow-up assists all hospitals, physicians, nursing homes, and other businesses in recovering past payments without difficulty. It is easier for healthcare providers to obtain reimbursements on time when there is a team that is always involved in the claims follow-up procedure.
  6. Dedicated Follow Up on Denied Claims – You can send a fresh claim request with appropriate modifications made, depending on the reason for denial. The A/R department may ensure that all claims are followed through to the conclusion by calling the insurance providers and figuring out the denial reason rather than waiting for it.

Importance of Denial Management

One of the most critical tasks in account receivable management is identifying claim denials at the appropriate time. Your billing team should be professional and knowledgeable in order to determine the reason for claim rejection and re-fill the claim as soon as possible. It’s also critical to look at denial patterns and come up with specific remedies to lessen the number of denials in the future.

Info Hub, an offshore medical billing company, not only tracks and manages each aspect, but also provides you with complete, real-time visibility into your earnings. Info Hub has been providing medical A/R services with a highly skilled staff of accounts receivable specialists who work with a variety of insurance carriers and are familiar with all of their regulations. We make certain that our customers face no encumbrance in receiving money for the services rendered.

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Top 3 Effective Denial Management Strategies Thu, 20 Jan 2022 13:28:47 +0000 What do you mean by Denial Management? 

Denial Management is the process of systematically investigating each denial, conducting analysis to determine the leading cause of why each claim was denied, analyzing denial trends to identify a trend by insurance carriers, and redesigning or re-engineering the measure to prevent or lower the risk of future Denial Management Services.

Numerous physician practices lose big bucks in revenue every year due to denied healthcare claims. Such denials are frequently the result of insufficient denial management policies and procedures.

Primarily, you would want to reduce the number of denials by identifying both the root cause and the coded cause, which is ideally done by the Info Hub denial management team. In addition, each instance of no reimbursement or payment which is less than anticipated should be investigated. Again, this is a vital step in maximizing your revenue cycle.

Top Denial Management Strategies provided by Info Hub:

Work Denials Based on Priority.

According to Info Hub’s medical billing expert team, your reimbursement is deferred several days when a claim is denied. Working capital is the core of the business, and your practice will be no exception; you require steady cash flow to keep offering excellent care to your patients. 

The Info Hub team adheres to the following protocols: 

  1. Each denial should be processed within 48 hours of receipt. 
  2. Each follow-up must be accompanied by written descriptions and pre-defined follow-up action with a due date for the following review. 
  3. Make an essential list of activity codes to be used in every circumstance, and explicitly state the following review date for each. 
  4. We ensure this is mentioned to the team and everybody comprehends how each code functions. 
  5. Keep your follow-up commitments, and ensure the case loop is closed and amendments are assured. 

Tracking and management of denials. 

Here are a few facts about denials: Nearly 50-60% of denials are not functioned appropriately, at least not in a reasonable timeframe, resulting in a 5-7% loss of revenue. Most healthcare systems lack a well-defined workflow for denial tracking and management. 

To effectively resolve denied claims, Info Hub offers optimized medical billing services, which we strongly suggest healthcare organizations integrate into their denial management workflow: 

  1. Make a very healthy list of CARC (claim adjustment reason code) and cluster them according to the similarity of subsequent follow-up actions. 
  2. Create a different AR bucket for denials, and within that bucket, make sub-buckets for similar concerns. 
  3. Evaluate which employees are better placed to work a particular type of denial and assign them the responsibility. 
  4. Retain a denial dashboard to track each denial received when this was worked on, when the next review date is, and what the inevitable output of the follow-up is. 
  5. A manual claims denial management system is still used by 31% of physicians. Suppose you do not have the right technology to track and work denials efficaciously. In that case, you can outsource the work to Info Hub, which will take complete care of the denial management of your organization. 

Analysis of Preventive Denial. 

The best approach to deal with denial claims is to avoid it in the first place. According to industry analysts, the overall denial rate for practices varies between 7 and 10%, when it should be no more than 4% and not over 2%. Preventive denial analysis is an underlying cause analysis of all denials received to decrease future denial rates.  

The Info Hub denial management team carries out the following analysis: 

  1. What prompted the denial? Was it because of a billing error, a coding issue, patient qualifications, the wrong payer was billed, or something else? 
  2. Is it possible that this denial could have been avoided?  
  3. What could have been done to avoid the denial? For example, if it was an eligibility problem, the team will go over your eligibility verification process and see if it needs to be tweaked. 
  4. Undertake an 80:20 analysis of your denials to determine which issues are causing you the most problems and how they can be resolved. 
  5. Do not seek to enhance each process from start to finish; instead, our denial management team at Info Hub recommends taking one step at a time for better results.  

Our Service for Denial Management Offering-

Info Hub’s denial management team is comprised of experienced professionals who: 

  1. Examine the reason for each denied claim. 
  2. Concentrate on resolving the problem. 
  3. Resubmit the insurance company’s request. 
  4. Make any necessary appeals. 

Info Hub recognizes that each denial case is distinct. We correct invalid or incorrect medical codes, offer supporting clinical documentation, attract prior authorization denials, comprehend any genuine denial cases to pass responsibility to patients, and effectively follow-up. Before re-submission, we re-validate all clinical information. 

Info Hub works with you to analyze denied claims and reduce the percentage over time. Get in touch with us at +1 (888) 694-8634 or 0422 4212 455 or visit us at

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3 Simple Hacks to Reduce Denials Tue, 17 Aug 2021 11:29:33 +0000 Researching on the denials and re-submitting the clean claims is quite a frustrating and time-consuming, tedious process. Thereby, it’s essential to have a claim denial management strategy in place so that you can quickly identify the reasons for the denial, resolve the issues, recover the payment, and prevent further denied claims. The longer you wait to re-submit the claims, the higher the chances of not recovering the maximum reimbursement amount from the payers. Or, even the worst part is that you won’t be able to recover a single penny.

Did you know that the healthcare industry experienced an average claim denial rate of 5-10%? However, the good news is that about two-thirds of these denials can be recovered with proper re-submissions, and nearly 90% of them are entirely avoidable.

Keeping in mind the above facts, how can you ensure the claim denial rate for your practice is below 5%? Let’s look at some of the everyday struggles arising from claim denial management and how you can improve them using proactive solutions.

Check Patient Eligibility and Insurance Coverage

The very first obligation of the front office is to verify the insurance coverage and the patient’s eligibility benefits before scheduling an appointment or providing the services. This will ensure that the submitted claims don’t get rejected for any such reason. In fact, it is mandatory to obtain an authorization number or a referral in certain circumstances, else the claims might get rejected by the payers.

Normally, the authorizations are active for a specific time range and might get expired if not used during that date. Also, some authorizations cover a period and/or a specified number of patients visits or treatments. However, one must note that there is no guarantee of payment even after obtaining the prior authorization.

To reduce the claim denials, make sure that the submitted claims are complete in all respects and must fulfill the following certain conditions:

  1. It must be evident and supported by the medical necessity and other related documents;
  2. It must be submitted or filed within the specified timeline; and
  3. It must be filed by the insurance provider already mentioned in the authorization or the referral.

File Claims On Time

The different insurance payers have different requirements for filing the claims. If you miss a deadline, you will miss the chance of getting the payment, i.e., your claim will be denied. Therefore, try not to risk the claim denials simply because of an office backlog or an oversight. Instead, make an effort to develop the processes and cheatsheets to ensure all the deadlines are timely met.

You can initiate the process by using the patient schedule as the beginning point to file all the claims on time. Thereafter, establish the routine of checking with the payers regarding receiving all the claims, even if submitted electronically. Even though the clearinghouse might depict a successful transmission to the insurance providers, several instances have been heard in the healthcare industry where even the electronic claims never reach the payer and slips through the cracks.

Keep track of the Claims

Keeping track of the claims throughout the entire payment process is another simple hack to reduce the denials. This will help you in identifying the problem and the probable solution to get the claim paid. A recent study by one of the doctors from the University of California found that the medical practices spend around 8-14% of their total revenue on the clerical follow-up of the rejected claims. Therefore, the need for an hour is to opt for a better and more cost-effective solution of collaborating with the offshore medical billing company in India. Such companies employ proactive solutions in processing the claims correctly to get the claims the very first time.

Moreover, if you still receive denials in claims, make sure to appeal them. According to the MGMA, only 35% of the healthcare providers appeal against the claim denials, losing the opportunity to get reimbursed. Therefore, this amounts to leaving the reimbursement money on the provider’s table provided the fact that such revenues can be recovered simply by automating the insurance billing procedures.

Additional Hack

Apart from the above simple hacks, another best way to reduce the claim denials is to outsource your medical billing tasks to one of the experienced medical billing companies in India. Outsourcing proves to be the best option, provided it has been outsourced to the Info Hub. Moreover, it can be quite challenging to deal with the denials using the trained staff compared to the expert billers and coders. In fact, it is the most cost-effective option to go in for the medical billing and coding services outsourcing to Info Hub and rely on their denial experts’ services. They are well-known for maintaining the perfect balance between denial management services and professionals dedicated to understanding the rejections and denials reasons to deal accordingly.