Wiki Denial Management

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coe_angela@hotmail.com

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Hi there-

Can anyone tell me how they run reports containing denial codes to look for trends of denials by payer? Do you get the reports from your PM system or do you get them from payers? AAPC advises these reports for effective denial management but I am unsure where to get them from. I would be grateful to hear all feedback as I'm sure there are a lot of different ways practices do this.

Thank you!
 
We get these reports from our own billing system. When your EOBs are posted, you should have reason codes for denials. For example, you'd want to identify denials due to a non-covered service, due to not meeting medical necessity, patient not identified, provider not authorized, etc. In fact, the EOB provides a denial code that you can use. You can report on these by payer to calculate the reasons for denial. So if you're getting a lot of denials for patient not being identified, it might be because you're not verifying their insurance status when they come for a visit. All healthcare billing systems have the ability to report, but as in any other situation...GIGO (garbage in, garbage out). If your payment posters or systems aren't accurately set up to report on the data, and you're simply posting an "adjustment" for all denials, you won't get the specificity you need to identify your issues.
This is an interesting part of the revenue cycle work that can help practices improve processes that will drive up revenue.
 
Thank you so much for the response Pam. Our posters have never been expected to capture denial codes so I would be starting from scratch if we consider that route.

Do you happen to know if any examples of payers who have or would be willing to provide reports like these?

We navigated around one payer portal yesterday and actually did find a tab where it looked like we could request a report titled "Claim trend - Denial reason" (by our Tax ID and provider NPI) but when we attempted to request it we were denied...I doubt we are set up to receive them...I plan to continue exploring that as well.

I would really like to try to work this into our denial management somehow. It seems like a perfectly logical approach that could be very effective.
 
I have never found that the reports generated by payers, if you can get them, to be useful for anything other than seeing long term trends. If you really want to get to the nuts and bolts of your reimbursement and denials, you should have your posters capture ALL the reason codes from the EOB when posting, and then run your reports from that data, as Pam Brooks suggested above. It will give a much clearer picture of what is happening to your A/R, in real time.
 
Thank you for the response Walker. I am meeting with our posters and evaluating our process to see if we might be able to start capturing this info.

Especially going into ICD -10 I would love to be able to run these reports and hopefully glean some helpful information for our practice.
 
As Walker22 states. It depends on the carrier. The one I work for has provider tools and one of those gives a breakdown of percent of denials by type. It doesn't hurt to call. Although that only shows trends, any data you can get can be helpful.
 
Denials

If you have not set your system to track the denials yet. I Would pull batched of denials and create your own report. It will take a little bit of time but it will be worth it. Also, ask the person working the denials, they are going to have an idea of the most common denials. This way you have something to work with while you are building your data in your system.
 
I would also like to say, if you have a clearinghouse that you pull your EOBs from, sometimes they also have denial reports that you can access. We don't track denial codes in our PM system unfortunately, but I can access the majority of our payers through the clearinghouse and get it that way.
 
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