Denials can have an adverse impact on your monthly revenue. Denial management can result in no or lower reimbursement. Few reasons for denials can include:

  • Incomplete or inaccurate insurance information
  • Lack of pre-certification or prior authorization
  • Coding related errors and omissions
  • Past timely filing limits
  • Medical necessity
  • Incomplete provider enrollment/credentialing issues

Best practice is to track the denials by:

  • Payer
  • Financial Class
  • Type of denial
  • Provider

TDP understands that an effective denial management program must address both historical and future claims, recovering otherwise-lost revenue and preventing future denials by adding meaningful First-Pass level edits.

TDP denial management program includes:

  • Analysis of the volume of denials, including a baseline analysis
  • Distribution of statistics across payers, providers, CPT codes, and causal CPT/ICD-9 relationships
  • Evaluation of age of denials in relation to claim expiration, refilling deadlines, etc
  • Understanding of the revenue impact on the organization

According to HFMA:

  • Denials account for 1% to 3% of net revenue potential
  • 90% of denials are preventable
  • 67% are recoverable given the proper tools
  • 50% of all denied claims are never refilled