Denial Management: In Simple Words

In 2019, I had the opportunity to be part of a transition team for one of Texas' largest hospital networks, working closely with their CBO team in Houston. Their goals were ambitious and transformative, aiming to streamline operations and enhance efficiency. Below were their 7 techniques to prevent medical billing denials

1. Verify that the patient’s insurance is active, confirm coverage details, and ensure all personal data is correct
2. Utilize current ICD, CPT, and HCPCS codes that accurately reflect the patient’s diagnosis and services provided. Regular training and updates on coding standards
3. Maintain detailed clinical records that support the medical necessity of the services rendered. Clear, complete documentation is crucial
4. Ensure all required pre-authorizations and referrals are obtained before delivering services. This proactive step is vital
5. Submit claims within payer-specified deadlines and monitor their status regularly. Timely filing helps avoid denials based on late submission
6. Conduct periodic audits of billing practices and claims submissions to identify common errors or trends leading to denials
7. Leverage modern billing software to automate claim submission, flag inconsistencies, and manage follow-ups efficiently

If you're struggling with high denial rates, AR 90+ exceeding 15%, credentialing challenges, posting issues, or coding errors, it's time to consult an expert or a billing company—because you may be losing more than you realize!