Role of AI in RCM Industry

Denial Management – Need of the hour

 

With leading hospitals and health care systems depending heavily on the revenue generated through insurance companies, it is to be noted that health insurers reject one out of five insurance claims in the US.

 

When such is the trend, the hospitals and healthcare systems must have a robust denial management process or a vendor who efficiently supports them in ensuring an efficient denial management process.

 

What is a Denial Management process?

 

The purpose of a Denial Management Process is to investigate every unpaid claim, uncover a trend by one or several insurance carriers, and appeal the rejection appropriately as per the appeals process in the provider contract.

 

In many cases, the rejection code used on a claim and the actual reason for rejection is not related. Therefore, the Denial Management Process seeks the root cause for the denial and the coded cause.

 

Knowing the difference between denied and rejected claims is an integral part of denial management. Claim denial occurs when a claim is processed and then disallowed by a payer. In contrast, rejection occurs when a claim is submitted to a payer with incorrect or missing data or coding.

 

Need for an efficient Denial Management process

 

An important goal for a Denial Management Process is to lessen the number of denials.

 

Denials or lower payments occur due to the following vital parameters

 

  • Procedure
  • Insurance carrier
  • Provider
  • Biller

 

If tracking uncovers a trend, providers or other appropriate personnel are informed so that procedures can be developed to avoid future denials. To manage denials, quick follow-up is a necessity. Regularly distribute denied claims to billing staff for management. In large practices, this should happen every day.

 

All correspondence is read daily for changes in billing or reimbursement policy from providers. This process allows providers to amend their policies and procedures to avoid denials. Make sure to follow the insurance carrier’s requirements for appeals. Otherwise, duplicate claims can occur.

 

Use denial codes to educate medical billing staff when there is denial due to incorrect medical coding if you do not have the resources to handle denied Claims Management in your medical billing department or are not achieving satisfactory results.

 

Denial Management is one of the critical aspects that every practice requires to improve its Revenue Cycle Management (RCM) and, ultimately, the quality of service to patients.

 

 

iMagnum – Your efficient Denial Management partner

 

We at iMagnum are outfitted with the best medical coding and billing experts, hand-picked for their ability in the area. These experts are constantly enrolled inconsistent staff education initiatives to have the most exceptional knowledge of the billing and coding guidelines.

 

iMagnum maintains a database of such endorsed combinations by various insurance agencies and is cutting-edge on something very similar. Our profoundly embraced coders guarantee that the generously compensated and most elevated affirmed mix of technique and diagnosis codes are used to ensure maximum payment and instant approval. In addition, our group of Denial Management experts works connected at the hip with the Coding, Verification, Billing, and Posting team to investigate, resolve and carry out remedial activities across the income cycle through the primary driver examination of any denial condition or non-payment situation.

 

We work with the existing data and our industry experts’ help; we provide solutions for most challenges faced by hospitals and medical facilities-related businesses. Some of those are listed below:

 

Lost revenue in expected collections due to lack of appeals for denied claims

Payer claims and rejections

Lack of resource bandwidth to accomplish tasks to recover lost revenue on denied claims

Failure to request assistance from key stakeholders like physicians or patients within the process

Vendor performance

 

Our Denial Management services include:

 

  • Identify and correct root causes of denials. All denials are routed to the denial analysis department. Denials are segregated into line items, and full denials
  • We work with all federal and commercial payers and have strong knowledge of their payment mechanisms
  • Streamline workflows for greater efficiency, faster appeals, and improved cash flow
  • Our denial management and reporting app give you real-time insights.
  • All claims are categorized into different follow-up groupings
  • Redundant processes are automated. This cuts back on cycle times. Recover money faster
  • Software that identifies, isolates, quantifies and categorizes denials to help you lower your denial rate and spot revenue leakage sources.
  • Help improve revenue cycle management and financial performance

 

There may be varied reasons for a claim’s rejection, it may be a modifier that is out of place or a combination of codes not allowed under the CCI edits, or it just could be that appropriate pre-authorization for the particular procedure, as mandated by the patient’s carrier was not obtained at the first instance of the patient coming in. For multiple challenges you face, we are the one-stop solution provider.