Efficiently working rejections and denials is essential to a successful practice revenue cycle. Any practice with high denial or rejection rates immediately feels the pinch in cash flow and the bottom line. While no practice wants to face these issues, there are a few easy ways to correct them if they do become a problem.
To start, it’s important to understand the differences between the commonly swapped terms “rejection” and “denial.” A rejection is created by a problem that comes up before adjudication by the payer. In other words, the claim never actually reaches the payer reimbursement process.
By contrast, denials are received from the payer after a claim has already gone through the payer adjudication process. A denial means the payer has reviewed the claim but determined it will not pay.
Once your entire back office team understands the difference between rejections and denials, they will need to start using a simple three-step process:
- identify rejections before they are even submitted to the payer;
- fix denials and any rejections that occur as quickly as possible; and
- make sure they don’t happen again.
After determining whether a claim has been denied or rejected, step one in your process is to identify possible rejections before they happen. Real-time, web-based claims clearinghouses often have scrubbing tools that provide an advantage in this regard by offering the ability to fix potential errors before submission to the payer. If your practice can correct these issues upfront, your risk of rejections or denials from the payer decreases.
Step two is to quickly rework any rejections or denials that do occur. Your clearinghouse should have tools that allow you to pinpoint explanations, so you quickly drill down to get rejection and denial codes. If not, and payers you work with use unclear denial explanations like “missing information,” you can use the healthcare code lists available from Washington Publishing Company to craft a knowledgeable response. There you’ll find every claim status code you’ll ever need, plus claim adjudication reason codes, remittance advice remark codes and much more.
Step three is arguably the most important one when it comes to streamlining rejections and denials workflow. You don’t want your staff to reinvent the wheel when there are standard solutions to common problems, so it is important to share knowledge with your staff regarding common errors, payer issues, technology/resources available, etc. in order to proactively combat the recurring causes of rejections and denials in your practice.
When people spot excellence in anything, they usually assume it’s the result of ideas or processes that are incredibly complex. On the contrary, it’s usually the result of the very simple process, such as the one described here. Use it to streamline your rejection and denial workflow and bolster your practice’s revenue cycle.