What is Denial Management?
Denial management is how healthcare organizations study the root causes of denials to implement corrective action to avoid future denials. Avoiding future denials is important because denials have a direct hit on the bottom line.
The Traditional Process
Let us look into how traditional healthcare organizations manage their denials.
The first step is to find and identify the causes that lead to denied claims. After distinguishing the root cause, the next step is to categorize and notify the department or team responsible for the denial to make corrective actions.
The emergence of value-based reimbursement in healthcare over the last decade has placed an increased emphasis on organizations to improve operational and financial efficiency.
Staying competitive is now comprised of not only a system’s ability to deliver quality care, but also delivering care at a lower cost, all while securing timely and accurate reimbursement.As health insurers have improved algorithms and systems for determining payment, healthcare organizations need to improve processes and technology to match.
One critical component is a vigorous denial management and improvement program to ensure that rigorous standards for payment are met.Approximately 60% of data on a claim comes from upstream departments such as patient access, clinical departments, HIM/Coding while the remainder comes from core technical configuration and automated rules.
Decoding the opaque insertion points of such data items is important for key decision-makers of an organization as preventing denials prior to occurrence needs to be an ongoing practice.
