Structure Your Denial Management Program for Success
Adopting this approach will boost your office’s financial performance. By following the steps outlined in “Seven Steps to a Successful Denial Management Program,” a HEALTHCON 2025 session presented by Kathy Pride, CPC, RHIT, CPMA, CCS-P, who has over 30 years of coding and auditing experience, you can safeguard your practice from unnecessary claim denials. Let’s review the seven steps she suggested in her presentation, along with some of her expert analysis to prevent claim denials in your office. Step 1: Establish a Team First you will need to establish a team of your office staff including coders, billers, revenue cycle analysts, practice administrators, compliance professionals, and clinical leaders or physicians. Their responsibilities will include: After compiling data, it will be important for your team to begin defining short and long-term goals to start reducing denials and improving your claim processing. Step 2: Implement a Tracking System Next, your office will need to figure out a tracking system that works best for your organization. Pride reminded the audience that this won’t be a one-size-fits-all situation, and you will need to tailor it over time to work for your staff. Because electronic health record (EHR) software will normally have tracking capabilities, she recommended using that as a way to begin tracking denial reasons. “Don’t rely solely on insurance denial codes,” said Pride. Be sure to set up tracking parameters to narrow down the insights you are looking for to better determine what is most important for your organization. For example, are you tracking for root causes of denials, the payer denial patterns, or the financial impact? Step 3: Analyze the Data The third step will be analyzing the data you are starting to accumulate. This means, you will begin to identify trends and patterns that you are seeing in that data. Find out your most common denial reasons. At this stage, it will help if you can identify the trends by payer, claim type, specialty, provider, and coder or biller to begin to develop a way to decrease future denials. After you have identified the information above, you can begin to target the underlying issues that are causing the denials directly. Are they from coding errors? Documentation gaps? Are they inappropriate payer denials? Step 4: Develop Targeted Education It’s now time to educate your staff and implement your office’s new action plan. Pride recommended starting with small solutions first, like implementing “scrubber edits” when applicable. You should also contact any payers that have been denying correctly coded claims inappropriately. Scrubber edits defined: This refers to the edits or corrections identified by a claim scrubbing process or computer program. This process involves reviewing medical claims before submitting them to insurance payers to ensure they are accurate, complete, and compliant with payer guidelines. Scrubber edits highlight potential errors, inconsistencies, or missing information that could lead to claim denials or delays. If necessary, create internal training programs to focus on problem areas with staff and bring them up to speed, which will prevent further denials. Include updated coding guidelines, standards, and payer specifics like medical necessity policies in that training. Step 5: Standardize Documentation Practices As all coders know, documentation is at the heart of coding and reimbursement. For this step, you will want to make sure your documentation policies are up to date, and this means creating clear and useful standardized templates for your staff to refer to. Follow compliance and payer policies as well as coding standards, and include medical necessity requirements and telehealth requirements; also, ensure all elements of a specific code are documented (e.g., measurements for lesions). Educate everyone in the office on this information, not just office staff. Physicians may also need to be reminded to “think in ink,” said Pride. In other words, if it isn’t in the record, it shouldn’t go on the claim. Step 6: Improve Claims Submission Process For this step, you will begin to use your new tools to review claims before your office submits them. Use your new checklists, claim scrubber edits, and templates to maintain accuracy throughout the process. This is also a good time to start a process that will route any potential issues to proper staff members who can fix those issues immediately. For example, coders can review documentation to add missing modifiers, correct a diagnosis code or query providers. Billers, on the other hand, can correct billing information like the patient ID, payer information, and place of service issues. Also make sure your staff is keeping up to date on any payer policy updates and that someone in your office is in contact with a payer representative to resolve any payer issues. Step 7: Monitor, Evaluate and Adjust As Necessary The final move will be tracking the progress of your office now that you have implemented these changes and updates. Take time to check your performance metrics by looking at your updated denial and recovery rates — and the impact it has had on your revenue. Continue to monitor the progress as needed by regularly reviewing and assessing your denial management strategies. Make any necessary adjustments and adapt your strategies based on the performance of your staff, the data you are seeing, and the feedback from fellow employees. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
