Wednesday, July 7, 2010

How to success in denial management

Claims Denial Management

Claims may be denied or underpaid for a variety of reasons.

Common reasons for denial or underpayment may include the following:

> Clerical errors, such as misspellings and transposed numbers

> Questions about medical necessity

> Improper use of diagnosis codes

> Incorrect procedure codes and/or modifiers

> Missing information

> Incorrect billing units

Insurance payers typically have a formal process that permits providers to appeal denied claims or inadequate reimbursement for drugs and/or services. If your claim is denied, you will receive an EOB from your local insurance claims processor explaining the reason(s) for noncoverage. You may resubmit the claim, requesting a redetermination of coverage. 

A well-written appeal letter can be very effective in obtaining appropriate reimbursement for a denied or an underpaid claim. Resubmitted claims should fully document the medical necessity for the patient in question and should include any supplemental information that may not have been included with the original claim.

Review Contracts Comprehensively

When assessing contracts, make sure the hospital can comply with the terms and identify provisions that might generate a high proportion of denials. Pay close attention to terms and limits for appeals. Members of the denial management team should participate in the hospital’s contract review process to ensure that contracts commit the facility to realistic and achievable goals from both contracting entities.

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