First we identify and categorize claim denials. This involves closely monitoring claim status reports, remittance advice (RA), and Explanation of Benefits (EOB) received from insurance payers. Once we identify the Denial, we try to find the root cause which could be due to coding errors, lack of medical necessity, incomplete documentation, or eligibility issues.

In many cases, denials are due to incomplete or inadequate documentation. We follow up with the healthcare provider to review the medical records and ensure all necessary information is included. This may involve gathering additional clinical documentation or clarifying the documentation with the healthcare provider responsible for the patient’s care.

If the denial is deemed incorrect or unjustified we work closely with the healthcare provider to prepare an appeal. This involves gathering supporting documentation, medical records, and any other necessary information to present a strong case for overturning the denial. The appeal is then submitted within the specified timeframe outlined by the insurance payer.

After the appeal is submitted, we track the progress of the appeal and follow up with the insurance payer to ensure it is being processed. This may involve contacting the payer’s provider relations or appeals department to obtain updates on the status of the appeal. Persistent follow-up helps ensure timely resolution and prevents delays in reimbursement.

As denials are addressed and resolved, we analyze trends and patterns in denials to identify areas for process improvement. This may involve updating coding practices, enhancing documentation procedures, or implementing staff training to minimize future denials.