Step 4: Prevent
Armed with data regarding denials, the next step is to promote a prevention campaign. Managing a denial prevention program at the practice level is a natural step in running an efficient practice; developing a cross-functional approach prevents the common problem of one team fixing an issue, while another team corrects the issue. Teams working in parallel on the same problem may end up working at cross purposes, duplicating the work of others or failing to root out the problem altogether. Categories of denials that are prime targets for your denial prevention program include registration, coding, authorizations and medical necessity.
- Registration is the first area to review for claims denials. Determine whether the issue was the patient’s insurance coverage or benefits eligibility, or a combination of both. Produce a feedback method from staff regarding these denials, and offer additional training to resolve any problems identified.
- Coding can cause a huge problem due to the complexity of procedural or diagnosis coding. The key to solving coding-related denials is seizing the opportunity at the initial determination of the code, not after the fact. Identify common services, and gain expert advice on how to correctly code them. Preventing coding-related denials means providing physicians and staff with excellent training about appropriate code selection and documentation.
- There’s only one solution to avoiding denials based on lack of authorization, and it is simple: Always secure the required authorizations. It is tedious, but creates a process for staff to follow to ensure every prior authorization is captured for every service that requires one. Start by instituting a system to automatically query appointments for the prior authorization status of all scheduled services. Additionally, alert staff to investigate prior authorization requirements for all in-office services ordered on the spot.
- It’s frustrating for physicians to receive denials when the payer claims the diagnosis provided does not support the need for the service. There are options to respond to—and even reverse some of—these denials. To develop internal knowledge among providers and staff, gather all of your insurers’ policies regarding medical necessity. Organize the policies by procedure or diagnosis and set the electronic health record to provide alerts for services an insurer has deemed not medically necessary or those services that have special requirements for medical necessity. Appeal any denials based on necessity by attaching your documentation of the patient visit, as well as any relevant, current medical literature in support of that service’s efficacy.
Managing denials is costly in terms of time and money, and establishing an effective denial prevention program is crucial to the long-term success of the revenue cycle. Staff can be educated to streamline the practice workflow, improve internal processes and get reimbursed in a timely manner for services provided.
For questions or training on coding, billing and denials management, contact the ACR practice management department at [email protected].
