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Are you managing your denials appropriately and efficiently? Do you have a denial strategy? Have you identified a spike in denials? Here is what you need to know.


The most important thing to identify is why are you getting denials. It is important to track each denial and the reason for denial, so you can identify any trends occurring. Once you have identified there is a trend, you will need to drill down to the cause of the denial. A trend could include a specific payer, physician, location, service line, diagnosis, or CPT code.


Many times, denials are caused by something on the front end, as payers don’t initially have the medical records to base a denial on. Are you missing preauthorization for services? Is there something being completed on the claim form incorrectly? Are you getting documentation requests and the documentation by practitioners is lacking? Is the correct insurance information being obtained at the point of Registration?


Once you determine the reasons for your denials, it is time to educate your staff. If you are getting a denial because staff isn’t getting pre-authorizations, you need to ensure that the responsible staff are aware of what services require preauthorization. If medical record documentation is causing denials, providers need to be educated as to the requirements. If you are receiving denials due to a non-covered service, ensure registration and clinical staff are aware of non-coverage.


After your staff/providers have been educated, you need to monitor their performance. Are they following the education you provided? Are there measures in place to ensure they are following new protocols, directives and adhering to any new policies created to prevent denials? Sample and audit appeals submitted by denial staff to ensure they are following all payer and provider organizational requirements. Watch for trending in this area. It is helpful to determine if a specific provider may be causing your denials.

Prevent Once

You have identified, analyzed, and educated your staff you want to ensure that you have put new processes, workflows, and policies in place to prevent future denials. Be transparent and share denial reasons with staff and providers and continue to ensure they have the resources and information needed to prevent future denials. Consider putting together a Denial Management team that meets monthly to discuss denials. It is helpful to have representation from Billing, Registration, Coding, Nursing and Providers present.

HCCS is a leader in Denial Management. Let us work with your organization to come up with solutions geared towards your denial trends. We can provide your organization education and training or we can manage the denial process for you.

Betsy Rios, CPC

Written by Betsy Rios, CPC

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