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Healthcare Denial Management Services
Identify, Manage, Monitor, and PreventDenial rates in healthcare claims vary widely, with estimates ranging from 5-25%, reflecting industry challenges and lack of standardization. Wise Medical Billing denial management services proven legacy and expertise are instrumental in minimizing denials, appealing rejected claims, and optimizing revenue recovery. Our commitment to excellence helps healthcare providers navigate denial uncertainties and achieve greater financial stability.
What is Denials Management Service
Healthcare denial management is a critical process that entails pinpointing the causes behind medical claims denials and implementing strategies to minimize them. A crucial aspect of this endeavor is the proactive implementation of tactics to enhance the rate of initial claims reimbursement.
To achieve effective denial management, it's imperative to consider the following factors:
- Complete visibility into the performance of a healthcare practice through in-depth analytics and reporting
- Identifying the reasons for denials of claims
- Reduction in the overall number of claims denied and increase in the number of claims paid
Root Cause Analysis
Effective denial management services in medical billing commences with a comprehensive root cause analysis. The most efficient approach to mitigate financial losses stemming from denied claims is to proactively prevent their occurrence. Below are some of the common reasons for claim denials across various medical specialties:
- Missing or incorrect information
- Duplicate claims
- Provider out of network
- Prior authorization
- Coordination of benefits
There are a variety of reasons why this may occur, including blank fields (e.g., Social Security number or demographic information) or incorrect plan codes, to coding errors such as missing modifiers.
Submitted claims for a single visit on the same day by the same provider for the same patient.
In the event that the services are provided by an out-of-network provider, the payer may deny the claim in whole or in part.
A claim may be denied if prior authorization is not obtained prior to the service being performed. The payer continues to update the list of services that require prior authorization.
If a patient is covered by more than one health insurance plan, claims can be delayed and even denied until the patient's coordination of benefits is updated.
- Medical necessity requirements not met
When a healthcare service is medically unnecessary, the policy does not cover it, and the payer disagrees with the physician about the type of treatment you need for your condition.
- The procedure not covered by payer
In most cases, this can be avoided by reviewing a patient's insurance policy or contacting their insurer before submitting a claim. The payer may deny a claim if a procedure performed is not covered.
- Exceeded timely filing limit
When a claim is filed outside the payer's required days of service, this should be considered when reworking rejected claims.
Get Perfect Denial Management with WMB
Assuring that your insurance claims are complete, accurate, and able to be processed by the insurance company is a significant accomplishment on its own, since it prevents your organization from potentially revenue losses.
Here are four more reasons you want to implement Wise Medical Billing Perfect Denial Management in your practice:
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- To avoid future denials, the process can help identify areas that require improvement.
- Our priority is to ensure AR aging is processed within the TAT (processing time) to maximize collection.
- As part of our denial management plan, we track, prioritize, and appeal denials based on case citations and state/federal statutes that support your entity's appeal.
- The collection and analysis of denial patterns provides insight into their root cause, enabling the denial management team to devise a permanent solution for these types of problems.
- By using our denial management service, a healthcare organization can also collect more candid information to support an appeal, which may result in a higher claim payment.
Using Data and Communication to Transform AR Management
When you have a patient with an outstanding balance, we provide you with relevant reports. Depending on your consent, we can take charge of communicating with the patients on your behalf. Our dedicated patient care team is here to handle the entire communication process in a highly professional manner, ensuring a clear and empathetic explanation of the amount owed. By entrusting us with this responsibility, you can enhance the likelihood of your patients making timely payments.
Benefits of the A/R and Denial Management Process
With our full suite of A/R and denial management services, we provide the following benefits to our clients:
Medical Revenue Management Experts
Who Understand Your Business
We acknowledge the challenges healthcare providers face in balancing patient care with financial responsibilities. If the demands of managing your finances are becoming overwhelming, it's the ideal moment to consider engaging a seasoned healthcare billing partner such as Wise Medical Billing.
Our company extends its AR recovery services to a wide spectrum of healthcare providers, including doctor's offices, hospitals, emergency centers, specialty care offices, imaging and radiology centers, laboratories, and surgical centers across the nation.
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