How to Address Healthcare Denials

I have been on both sides of insurance company denial process for decades; as a practicing physician, hospital and health system CMO, Vice President of Medical Affairs for a physician owned health insurance company and medical director of risk bearing health system management services organization that has delegated utilization management. I learned how to reduce denials to near zero. Here are my top ten tips to avoid denials. 1. Most denials are simply due to referral to a non-contracted provider. Be sure you refer patients to contracted in-network providers. 2. Many denials are for non-covered benefits. For example, there are many things that Medicare doesn't cover like diapers or TED hose. Know what is covered and what isn't. 3. Many denials have errors; incorrect CPT and ICD 10 codes, wrong dates of service etc. Make sure your billing staff knows what they are doing 4. Many denials are because what is requested doesn't align at all with the medical literature or guidelines. Base your diagnostic and therapeutic decisions on peer reviewed medical literature. When in doubt, consult UPTODATE 5. Many denials are for unnecessary and hideously expensive brand name drugs. Prescribe generics whenever possible 6. Many denials are for unnecessary imaging. Always refer to the American College of Radiology Imaging Appropriateness Criteria when considering high tech imaging 7. Many denials are because of excessive radiation exposure in children. Always use Choose Wisely Guidelines and Image Gently Guidelines. Do not expose children to CAT scans if an ultrasound or MRI will do. 8. Many denials are for insufficient or no clinical documentation. Make sure you provide enough history for the physician reviewer to understand what you are requesting and why 9. Some denials are for off-label use of medications. Stick to what the FDA has authorized 10. Some denials are because the request is for an experimental treatment. Insurance companies generally don't fund research!

Denial Management is the process of identifying, analyzing, and resolving denied claims in medical billing. Here's a detailed overview: Steps in Denial Management: 1. Denial Identification: Recognize denied claims through claims tracking, payer notifications, or patient inquiries. 2. Denial Analysis: Investigate the reason for denial, including: - Reviewing claim details and supporting documentation - Verifying patient information and insurance coverage - Identifying coding, billing, or compliance errors 3. Denial Categorization: Classify denials into categories, such as: - Medical necessity - Coding or billing errors - Authorization or eligibility issues - Timely filing or submission errors 4. Denial Resolution: Take corrective action to resolve denials, including: - Correcting and resubmitting claims - Appealing denials with supporting documentation - Obtaining additional information or clarification from payers - Educating staff on accurate billing and coding practices 5. Denial Prevention: Implement measures to prevent future denials, including: - Updating billing and coding guidelines - Enhancing staff training and education - Improving claims scrubbing and editing processes - Conducting regular audits and compliance reviews Key Performance Indicators (KPIs) for Denial Management: 1. Denial Rate: Percentage of denied claims out of total claims submitted. 2. Denial Resolution Rate: Percentage of resolved denials out of total denials. 3. Appeal Success Rate: Percentage of successful appeals out of total appeals filed. 4. Denial Turnaround Time: Average time taken to resolve denials. 5. Revenue Recovery: Amount of revenue recovered from denied claims. Effective denial management reduces revenue loss, improves billing efficiency, and enhances patient satisfaction. #RCM #MedicalProvider #MedicalBilling #Credentialing #Officebilling #AccountReceivable #Billing #coding

📌FACT: 30% of a medical practice’s revenue is LOST due to poor billing processes. Let’s change that. IPPs, are you unknowingly giving away your hard-earned revenue? You see patients. You provide great care. But if your billing and collections aren’t optimized, you’re working harder and earning LESS than you should. Billing & Collections 101 Guide 1. Verify Insurance Before the Appointment 🔹 The #1 reason for claim denials? Patient ineligibility.  🔹 Don’t assume coverage—verify eligibility 48 hours before every visit. 2. Submit Claims DAILY (Not Weekly or Monthly) 🔹 The longer you wait to submit, the longer you wait to get paid. 🔹 Make daily claim submission a standard practice to speed up reimbursements. 3. Track and Follow Up on Unpaid Claims 🔹 50%+ of denied claims are never appealed. That’s lost money. 🔹 Set up a claims tracking system to follow up on unpaid claims within 7-14 days. 4. Collect Patient Balances at the Time of Service 🔹 The longer a bill remains unpaid, the less likely it is to be collected. 🔹 Implement point-of-service collections and offer easy payment plans (online, text, autopay). 5. Know Your Payer’s Rules and Contract Terms 🔹 Insurers change policies constantly—are you staying updated? 🔹 Negotiate better contracts & ensure you’re billing at the highest reimbursable rate. Your revenue cycle is the backbone of your practice’s financial health. Don’t let inefficient billing drain your income. At VaQya LLC, we help IPPs maximize collections, minimize denials, and take full control of their revenue. Want a free RCM health check? DM me “Billing” and let’s talk. #revenuecycle #physicians #physicianownership #privatepractice

𝐇𝐞𝐚𝐥𝐭𝐡𝐜𝐚𝐫𝐞 𝐂𝐥𝐚𝐢𝐦𝐬 𝐃𝐚𝐭𝐚 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 𝐒𝐨𝐟𝐭𝐰𝐚𝐫𝐞 Healthcare is losing millions to claim denials. The good news? Most denials are preventable. Here’s how Claims 𝐃𝐚𝐭𝐚 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 𝐢𝐬 𝐭𝐫𝐚𝐧𝐬𝐟𝐨𝐫𝐦𝐢𝐧𝐠 𝐫𝐞𝐯𝐞𝐧𝐮𝐞 𝐜𝐲𝐜𝐥𝐞 𝐦𝐚𝐧𝐚𝐠𝐞𝐦𝐞𝐧𝐭: 𝟏. 𝐓𝐡𝐞 𝐏𝐫𝐨𝐛𝐥𝐞𝐦: 𝐈𝐧𝐞𝐟𝐟𝐢𝐜𝐢𝐞𝐧𝐭 𝐂𝐥𝐚𝐢𝐦𝐬 𝐏𝐫𝐨𝐜𝐞𝐬𝐬𝐢𝐧𝐠 🔹 High denial rates lead to massive financial losses. 🔹 Most rejected claims go uncorrected and unresubmitted. 🔹 Lack of root cause analysis means errors keep repeating. 𝟐. 𝐖𝐡𝐲 𝐓𝐫𝐚𝐝𝐢𝐭𝐢𝐨𝐧𝐚𝐥 𝐌𝐞𝐭𝐡𝐨𝐝𝐬 𝐅𝐚𝐢𝐥 ❌ 𝐓𝐞𝐜𝐡𝐧𝐨𝐥𝐨𝐠𝐲 𝐆𝐚𝐩𝐬: No proactive tools to detect early issues. ❌ 𝐏𝐫𝐨𝐜𝐞𝐬𝐬 𝐈𝐬𝐬𝐮𝐞𝐬: Manual data entry and slow insurance verification. ❌ 𝐒𝐭𝐫𝐚𝐭𝐞𝐠𝐢𝐜 𝐖𝐞𝐚𝐤𝐧𝐞𝐬𝐬: No long-term plan to reduce denials. 𝟑. 𝐓𝐡𝐞 𝐏𝐨𝐰𝐞𝐫 𝐨𝐟 𝐂𝐥𝐚𝐢𝐦𝐬 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 ✅ 𝐃𝐚𝐭𝐚-𝐃𝐫𝐢𝐯𝐞𝐧 𝐑𝐨𝐨𝐭 𝐂𝐚𝐮𝐬𝐞 𝐀𝐧𝐚𝐥𝐲𝐬𝐢𝐬: Identifies patterns behind denials. ✅𝐈𝐧𝐭𝐞𝐫𝐚𝐜𝐭𝐢𝐯𝐞 𝐃𝐚𝐬𝐡𝐛𝐨𝐚𝐫𝐝𝐬: Visualize denial trends, CPT codes, and payer behaviors. ✅ 𝐀𝐈 & 𝐌𝐚𝐜𝐡𝐢𝐧𝐞 𝐋𝐞𝐚𝐫𝐧𝐢𝐧𝐠 𝐈𝐧𝐭𝐞𝐠𝐫𝐚𝐭𝐢𝐨𝐧: Automate insights and optimize workflows. ✅ 𝐑𝐞𝐚𝐥-𝐓𝐢𝐦𝐞 𝐌𝐨𝐧𝐢𝐭𝐨𝐫𝐢𝐧𝐠: Spot issues early in the revenue cycle. 𝟒. 𝐓𝐡𝐞 𝐑𝐞𝐬𝐮𝐥𝐭𝐬 𝐒𝐩𝐞𝐚𝐤 𝐟𝐨𝐫 𝐓𝐡𝐞𝐦𝐬𝐞𝐥𝐯𝐞𝐬 💰 Reduced denial rates to industry best standards. 💰 Millions saved from preventing lost reimbursements. 💰 Sustained improvements through continuous data-driven strategies. 𝟓. 𝐇𝐨𝐰 𝐭𝐨 𝐌𝐚𝐤𝐞 𝐈𝐭 𝐖𝐨𝐫𝐤 📌𝐄𝐱𝐞𝐜𝐮𝐭𝐢𝐯𝐞 𝐁𝐮𝐲-𝐈𝐧: CEOs, CFOs, and COOs must prioritize claims analytics. 📌𝐃𝐞𝐝𝐢𝐜𝐚𝐭𝐞𝐝 𝐃𝐞𝐧𝐢𝐚𝐥 𝐓𝐞𝐚𝐦𝐬: Root cause analysis experts to track trends. 📌𝐏𝐃𝐂𝐀 𝐌𝐞𝐭𝐡𝐨𝐝𝐨𝐥𝐨𝐠𝐲: A continuous improvement strategy for long-term success. 𝐘𝐨𝐮𝐫 𝐫𝐞𝐯𝐞𝐧𝐮𝐞 𝐜𝐲𝐜𝐥𝐞 𝐬𝐡𝐨𝐮𝐥𝐝𝐧’𝐭 𝐝𝐫𝐚𝐢𝐧 𝐦𝐨𝐧𝐞𝐲, 𝐢𝐭 𝐬𝐡𝐨𝐮𝐥𝐝 𝐦𝐚𝐱𝐢𝐦𝐢𝐳𝐞 𝐢𝐭. If you're looking for 𝐂𝐥𝐚𝐢𝐦𝐬 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 𝐞𝐱𝐩𝐞𝐫𝐭𝐢𝐬𝐞, let’s connect and discuss solutions tailored to your organization. 𝐏.𝐒. 𝐖𝐡𝐚𝐭’𝐬 𝐲𝐨𝐮𝐫 𝐛𝐢𝐠𝐠𝐞𝐬𝐭 𝐜𝐡𝐚𝐥𝐥𝐞𝐧𝐠𝐞 𝐰𝐢𝐭𝐡 𝐜𝐥𝐚𝐢𝐦 𝐝𝐞𝐧𝐢𝐚𝐥𝐬? Drop a comment or DM me we’re here to help!