Denial Management

Swift Denial Resolution, Optimal Cash Flow

Denial Management

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.

Do you know Why it happens?

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.

Denial Management Process

Our experts at Stream RCM follow the below process for denial management:

Track status

Follow up with the insurance company to track the status of the claim.

Identify Denial Issues

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.

Refile the claim

Track the status of the claim with the insurer and follow up till the claim is resolved. File appeals are needed.

Resolve the claim

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.

What Are Most Common Denial Issues in Medical Billing?

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.

Common Categories of Denial in Medical Billing

Reasons for denial
in medical billing

  • Lack of Prior Authorization
  • Errors on Claim Forms
  • Late Claim Submission
  • Inadequate Medical Necessity

Stream RCMs efficiency
to reduce denials

Patient Eligibility

Prior Authorization

Billing Mistakes

Medical Necessity

Focus on
Getting Claim Resolved

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14430 Ocean Point, El Paso, TX 79938

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