RCM Matter leads the way in resolving denials and optimizing cash flow. Explore our proven denial management solutions, crafted to streamline billing processes and secure the revenue your organization deserves
Denial management and rejection management are two distinct concepts that often need clarification. Rejected claims refer to claims that have yet to be processed by the payer’s adjudication system due to errors and must be corrected and resubmitted by the billers. On the other hand, denied claims are claims that have been processed by the payer but have been denied payment.
Healthcare organizations should prioritize addressing both rejected and denied claims. The claims rejection management process can help identify and correct issues with the claim. In contrast, denied claims represent potential loss or delayed revenue if the claim is eventually paid after appeals.
Billers must conduct a root-cause analysis to successfully appeal denied claims, address the underlying issues, and file an appeal with the payer. Healthcare organizations must continuously address problems with front-end processes to prevent denials from recurring in the future and maintain financial stability.
As RCM Matter, a leading provider of Revenue Cycle Management services, our Denial Management outsourcing services comprise a comprehensive approach designed to optimize the financial health of healthcare organizations.
Our main task is to figure out which claims got denied and why it happened. We sort these denials into groups based on the reasons they were rejected, like pieces of a puzzle. The next step involves a close investigation to understand the core issues causing these denials. It's like playing detective – we want to uncover the key problems that keep showing up. So, it's not just about spotting denials; we're trying to get to the bottom of why they occur. This means checking for errors in how things were coded, making sure billing information is correct, and ensuring all necessary paperwork is in order. By understanding these root causes, we can better address the issues in the following steps, such as when we appeal denied claims or work to prevent the same problems from recurring. This initial phase lays the foundation for a strategic approach to handling denials effectively and intelligently.
Claims may be denied if patient demographics, insurance information, or referral/authorization documentation need to be included or completed. Therefore, ensuring that all necessary details are complete and accurate is crucial
Assigning incorrect medical codes, like diagnosis (ICD-10) or procedure codes (CPT/HCPCS). can result in denials. This can happen when the codes need to be corrected, do not match, or there needs to be more documentation to support the codes that have been billed.
It may be allowed if there is more proof to show that a medical procedure or service is necessary. To avoid this, thorough documentation is essential to justify why the treatment or service is needed.
Submitting multiple claims for the same service, intentionally or accidentally, can result in denials. Payers usually have regulations and checks to detect and reject repetitive claims.
Every insurance company has a set deadline for submitting claims. If the claim is not offered by the deadline, it may be denied based on the timely filing rules.
Certain insurance plans may require pre-authorization or referrals for specific procedures or specialist visits. Fulfill these requirements or document them correctly to avoid denied claims.
When a patient has multiple insurance policies, it's important to coordinate benefits properly. You can avoid having claims denied by correctly blending the benefits between the primary and secondary insurance plans.
The claim may be denied if a patient's insurance coverage has expired or is not qualified for the service billed.
Errors in the billing process, such as inaccurate patient or provider details, mismatched codes, or typos, can result in denials.
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