Mastering Denials Management

Payer denials have become a focal point in healthcare over the past year and with good reason, both Medicare (CMS) and Commercial payers like United Healthcare (UHC) and Aetna have denied more claims in 2024 for a myriad of reasons. Over the past three years, there has been over a 50% increase in payer denials. Many practices are wondering how we can combat these tactics from payers and remain profitable. It is a growing burden and one that has to be considered for continued practice growth in the Revenue Cycle Management (RCM), process as well as Coding and Billing.

Many practices struggle with documentation that supports the services billed, so it is no wonder that both Government and Commercial payers are stepping up their post-payment reviews and combing through provider documentation to find reasons to deny and recoup payments. With that, there has been a surge in these types of audits to well over 100 percent of what it was in 2023, thus adding to the three-year increase in payer denials.

For practices to better understand the reasons payers are requesting monies retrospectively post audit, there are some core issues that both CMS and Commercial payers are denying claims, below are some of the most frequently seen:

Incorrect Coding/Billing
Missing Documentation/requests for documentation not submitted, or on time
Failure to show Medical Necessity for submitted services

In order for a practice to improve in these areas, it is important to understand some facts:

On average, more than 90% of claims are rejected on first submission, which is a preventable problem
More than 70% of first-denied claims can be reversed if you have the proper staff in your Coding and Billing departments
Employing Certified Coders and Billers affords infinite opportunities to improve revenue gain with better RCM processes

At Zenmed Solutions Inc., we are experts in all of these areas and can work with your practice and develop a personalized approach to improve your bottom line.

In a recent study by MDAudit https://www.mdaudit.com/resource/report/2024-benchmark-report/

They focused on the surging denial crisis in healthcare. The report indicated the volume of external audits has negatively impacted the cash flow of many provider organizations across the United States and that would align with the downward trend in profit margins over the past three years. This comprehensive report includes real-time data which represents the first three quarters of 2024 and has been extrapolated from a combined network of upwards of 650,000 providers and over 2,200 facilities. Below is a breakdown of key points from the report:

Auditing Analysis – Over $8 billion audited professional and hospital claims
Charge Analysis
Denial Assessments – Over $150 billion in denials from both commercial and government payers
Over 5 billion claims and remittances were used to benchmark the data in the report

The data collected from MDAudit has created an opportunity for providers and practices to improve denial ratios and increase revenue flow by implementing better RCM practices in offices. The Team at Zenmed Solutions, Inc., would make a great partner to help your practice improve in these areas.

Zenmed Solutions Inc. realizes that there are a variety of integral Key Performance Indicators (KPI), that will enhance a practice’s revenue stream, when the correct staff and processes are implemented. We have developed some KPI’s that we recommend and can implement and provide for any practice:

KPI for Denials Management:

Eligibility & Insurance Verification: The first part of every claim’s life begins with eligibility and insurance verification. If a patient’s insurance coverage is not verified before their appointment, there is no way of knowing if the claim will be submitted to the correct payer or if the insurance is active. If a practice does not verify ahead of an appointment, that is a surefire way to guarantee many denials and then you must chase the patient down for the correct insurance and sometimes payment. The best practice is to verify insurance ahead of the appointment and when the patient arrives, take a copy of the front and back of the insurance card. This will mitigate denials and will assist with ensuring that the services provided will be paid for by the correct payer.
Coding/Billing: It is mission critical that Certified Coders are employed so that they can properly review provider documentation to support services rendered and billed before being submitted to payers. Coders deploy a variety of tools that include ICD-10CM & PCS, CPT, and HCPCS to E&M services and procedures, as well as verify and sometimes assign diagnosis codes. All this translates into dollars that the practice should receive via claim reimbursement from payers.
Claims Submission: Once the claim is coded, the Billers take over and perform a pre-submission of all the claims to the clearinghouse. Once that happens, then they should check the reports to see if any claims have been kicked out for coding issues, like a wrong modifier or CPT code, etc. Once all is clear, then the claims are submitted to the various payers for review and payment. Accurate claims submission is vital for prompt payment, as errors can result in denials or delays.
Denials Management: After all the claims are submitted, the payer will review and hopefully process the payment without delay or prejudice to the practice. If a claim is denied, it must be processed through the clinic’s denials management department, within a short time, to comply with a request to reprocess from the payer. This is where your coders and billers need to be adept at navigating the many ways payers can deny claims and take immediate action to resubmit the claim with what the payer is asking for or call to find out what can be corrected if it is not clear, to receive payment.

The Team at Zenmed Solutions Inc., also realizes that practices struggle with submitting Clean Claims, which speaks directly to a practices Coding and Billing departments. Our Teams can assist with all of these as needed. Zenmed Solutions has created an RCM Tool called BLISS – “ Barometric Live Intuitive Solution(S).” BLISS is intuitive and is able in real time to Track, Categorize, Strategize, Correct & Learn (TCSCL) the specifics to any practice and help improve all aspects of Revenue Cycle Management (RCM).

Some of these processes include the following:

Correct Procedure code(s)/CPT
Correct Diagnosis code(s)/ CD 10CM /ICD 10PCS
Correct HCPCS codes
Correct Modifier(s)
Keeping abreast of Payer Reimbursement policies and LCD/NCDs for CMS
Date of denial/rejection if a denial is received, as the payer only allows a certain amount of time to appeal
Remittance identification number
Denial / Rejection Code(s)
Description of Denial / Rejection Code(s)- coding error, patient registration error, precertification

Ensuring A Successful Future:

There is a definite race to be better in healthcare and not only is patient care at the forefront but so is financial solvency. The core of any practice is the Revenue Cycle Management Team (RCM), whose duty is to ensure financial success by keeping up to date with the ever-changing world of payers and their reimbursement policies, (or strategies as I like to call them), to avert payment delays and/or denials. A good RCM Team will work cohesively with each other and ensure timely submission of claims and appeals, as well as perform coding and billing audits, on the front and back ends, review documentation against codes to be billed for encounters and ensure payer payments are correct and timely.

Practice Mantra:

“If you want to get paid for the work you do and the patients you treat, then it is paramount to ensure that clean claims are submitted every time, with accurate coding, billing, and clear, concise documentation”.

Contact Zenmed Solutions Inc., today for a free consultation and audit of your practice and let us help you revive, renew and improve your practice.

Happy Coding!

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