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Denial Management: Practical Answers to Tough Questions

No matter how good your claims submission process, denied claims are going to happen and management of those issues will be a fact of life for medical practices. Here are some answers to a few commonly asked questions to help ease your denial management activities:

How can our practice generate a good payer compliance report? 

A payer compliance report can be developed using the payer-specific data that you are currently tracking, including denial rate, average days outstanding on submitted claims and first pass rate. If your practice management system or clearinghouse doesn’t offer this information, you can manually track these figures using a payment posting denial tracking worksheet.

Sometimes when we submit a corrected claim, they are almost always denied as duplicate. If it is a small correction such as a modifier addition, it is not recognized electronically. The payer wants us to send the corrected claim on paper, but this slows our process. What recommendations do you have? 

Many states have a prompt payment law which specifically defines “clean claim.” If the payer is not in compliance with the law and how “clean claim” is defined, you may have legal recourse. Review the state prompt payment law and/or discuss this with a healthcare attorney. Be sure to cite the clean claim definition in appeals and seek interest payment, if stipulated in the law.

What’s the best way to approach appeals when a payer doesn’t give specific reasons for upholding a denial?

A carrier’s failure to disclose the complete denial information often stems from the provider not establishing an authorization to represent the patient on appeal.

If at all possible, submit this form as early as possible in the claims process, but also be sure you always submit a signed authorization form with your appeal request.

What is the difference between a “bundling denial” and an “inclusive denial”? Aren’t they the same essentially?

Yes, they are similar and require the same appeal approach. You need to appeal by requesting: 1) release of the coding/bundling guidance, and 2) review of the denial by a certified coder. If the denial is related to a recent change in the coding/bundling guidance, demand the date of notification of the change and then discuss the changes with the provider representative, including ways to ensure you are alerted to the changes early on.

Who is responsible for getting a pre-certification—the provider or patient? In the event of a denial for pre-certification, can we bill the patient?  

Typically the provider is responsible for obtaining pre-certification and cannot bill the patient for lack of pre-certification per the contract terms. If there is no contract between the provider and payer, however, the patient must obtain the out-of-network pre-certification and typically can be billed if the pre-cert is not obtained.

Clear communication with payers is essential to a smooth denial management process. What other questions do you have?