Prevent Denials in your Medical Practice & Increase Revenue

Drive denials down to drive revenue up with these strategies you can implement in your practice.  

Billing is one of the most critical processes in the success of every medical center. Most people involved in directing and operating medical practices understand that billing and coding require daily attention to detail, trained staff, and a solid tracking of ever-changing payer guidelines. 

One main point in the billing process that needs special attention is denials. Some practices view denial management as the “catch-all” for unresolved claims. This attitude creates a negative perception and makes it uninviting for staff members to dig in and resolve open issues. 

However, managing denials is not enough for practices to succeed. A comprehensive approach focusing on denials prevention and management can change your practice´s perspective and help you increase revenue. 

The good news is that according to MGMA (Medical Group Management Association) data, 90% of denials are preventable.  

Here are some strategies to prevent denials from occurring and ensure you get paid for your work: 
1. Analyze the main causes

Understand what the true denial reasons are. Deep dive into your denial reports and identify the main reasons your claims are denied. Be sure to track and analyze them at least monthly.  

At AdvantEdge, we analyzed a sample of 30,000 claims and the resulting 1500 “first pass” denials and found that most of the denials were caused by a small number of reasons. These reasons include patients not insured or incorrect insurance information such as transposed digits, old insurance cards, etc. 

According to an MGMA Stat poll, where the association asked healthcare leaders what the root cause of claims is denials/pends in their organization:  

  • 36% answered “missing information.”  
  • 31% reported “prior authorization.”  
  • 15% said “eligibility.”  
  • 5% said “out of network.”  
  • 13% responded “other.  
2. Apply the 80/20 rule

An MGMA article stated that most practices find that 80% of their denials result from 20% of the problems. Take the twenty percent of issues that cause eighty percent of the denials and identify the ones to be addressed with:  

  • Staff education.  
  • Procedures and job aids.  
  • Physicians’ involvement.  
  • Billing staff training.  

As with implementing any complex process, start eliminating one root cause at a time. Choose to focus first on one of them. Once you have selected it, make a plan to reduce those denials. Remember to set realistic goals for improvement. 

This will enable staff members to gain insight into the process, recognize some substantial wins, and see the fruits of their work. 

3. Train your front-desk staff periodically

Accurate billing starts the first time a patient interacts with your practice. Improving the quality of information at the front end will result in significant benefits at the back end. Train your front-desk staff, especially schedulers and intake personnel. 

Schedulers should know that obtaining or confirming insurance information is a crucial job responsibility for every call. A good practice is verifying the patient´s eligibility when scheduled, when they present, or both. This procedure also allows the practice to know the exact amount the patient is responsible for and collect some (or all) of it before the appointment. 

Your staff should have the information needed complete to proceed with the appointment and make sure you collect every dollar you earn. Ensure you include referring physicians´ office staff and physicians on periodic training. 

4. Pay attention to payer patterns

As your denial prevention process matures, pay particular attention to payer patterns. In today’s changing billing environment, you may experience jumps in denials from payers that had low rates just a few months ago. Analyze main denials that cause claims not paid in full – those should be considered partial denials. 

Payer patterns and trends are beneficial for these cases since they equip the practice for discussing payments versus contracted rates with the payer. 

To learn more about preventing denials and increasing your practice´s revenue, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.