If your approach to denials management focuses on getting denials reversed, you’ve got it wrong.
Because it’s so costly to rework a denial, it’s critical to identify and fix your problems upstream.
- Use analytics to find patterns.
- Drill down to understand the root causes.
- Fix problems to reduce your denials rate.
#1: Identify the problem
First, find your outliers. Where are your highest denial rates – be it problem workflows, coders, clinics or payers.
Analytics will help you quickly determine the cause of your biggest problems. Which workflows cause the most denials – verifying eligibility, obtaining authorizations, provider credentialing, submitting timely claims, something else?
Look for clinics, claim coders and payers with elevated denials. Focus there.
#2: Understand the problem
Drill down to understand your denial scenarios.
Clues to rejection can be found by analyzing combinations of claims adjustment reason codes and remittance advice remark codes.
Different reason/remark code combinations may look like the same source rejection, but may have very different root causes. Once you identify the reason/remark code combinations that account for a sizable proportion of your denials, zero in on finding the underlying causes.
#3: Fix the problem
Now go upstream and fix the problem – be it people, process or technology.
The solution might be better training, clearer procedures, changes in processes, different staffing, new or improved technology or configurations. Address the problem and you’re on the path to fewer denials.