Denial Management is the process of systematically investigating each denial, performing a root cause analysis of why each claim was denied, analyzing denial trends to uncover a trend by one or more insurance carriers, and redesigning or re-engineering the process to prevent or reduce the risk of future. Denial in medical billing is a refusal by a health insurance company to pay for services or products it has agreed to cover.
Denials can happen for various reasons but are most often the result of an incorrect bill
or claim. When a health insurance company denies a claim, it can leave the provider
responsible for the full cost of the services provided. Enforcement usually occurs because
an insurer wants to return some of the money paid to the provider. Payment may have
been made through a healthcare financial intermediary, such as an insurance company
or Medicare.
A bill may also be denied if the professionals providing solutions are not medically
appropriate. Denial management services in medical billing extend beyond medical care
services. Denial of a health insurance claim can include insurance providers that won’t
pay for things like devices, diagnostic tests, services that are not covered by the
insurance, products that are not covered by the insurance, screening at a medical facility,
or if the provider who receives the bill is not licensed, that isn’t licensed by a licensed
entity.
Our experts at Stream RCM follow the below process for denial management:
Follow up with the insurance company to track the status of the claim.
We identify denied claim, analyze the reasons, and follow up with the insurance company to check if additional information is needed and address the issues.
Track the status of the claim with the insurer and follow up till the claim is resolved. File appeals are needed.
Posting of denials and rebilling to the secondary insurance company, transferring the balance to the patient, write-off the amount, or sending the claim for processing.
Denial in medical billing is when an insurance company decides not to pay for services or products they have agreed to cover. This could occur due to various factors. The services or products do not meet the insurance company’s policy or guidelines. The provider is overcharging the insurance company. These denials are categorized as soft and hard, some can be re-sent, and others cannot.
Lack of Prior AuthorizationErrors on Claim FormsLate Claim SubmissionInadequate Medical Necessity
