Create a Viable Strategy for Resolving Clinical and Coding Denials
As healthcare providers face multiple challenges, such as rising labor shortages and declining reimbursements, they must maximize revenue cycle recovery. Claim denials, a major source of revenue loss for healthcare practices, are on the rise across all payer types. Coding-related denials are a significant source of denials. A thorough and focused denial management medical billing company will aid in reducing revenue loss. This article identifies the sources of revenue leakage due to clinical and coding issues and proposes a comprehensive solution to address them.
Causes of Revenue Loss as a Result of Clinical and Medical Coding Issues
The following are the primary causes of revenue loss in the revenue cycle due to clinical and medical coding issues.
Discharges Have Not Been Fully Billed
Due to DNFB issues, medical practices and hospitals lose 3-5% of their revenue. Healthcare provider organizations lose revenue due to a lack of knowledge of reimbursable procedures or a delay in documenting all medical services provided. Expert medical coders who understand the medical specialty can assist in locating these DNFB problems.
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Problems With Coding Quality
Denials occur when medical coders incorrectly code a patient-physician encounter. To avoid such denials in the future, healthcare providers must invest in a coding audit function to perform quality checks and improve coding quality by using practice audit and reporting services.
Denials of Clinical Validation
Clinical validation denials are caused by medical codes that do not support the clinical services provided. Better clinical documentation to validate clinical procedures, as well as improved coordination between clinical documentation and coding personnel, are required for an effective appeals strategy for clinical validation denials. Due to increased scrutiny for clinical documentation issues, a healthcare organization must provide compelling documentation as evidence, which often necessitates discussions with physicians.
A Strategy for Effectively Appealing Clinical and Other Denials
Denial management and prevention necessitate effective cross-functional collaboration and ongoing discussions to eliminate the avoidable causes of denials. When denials occur, medical practices and hospitals must implement a coordinated and collaborative appeals strategy that includes the following steps:
Most denial management experts agree that the first step in denial management and prevention is ongoing analytics on the top reasons for denials. Front-end, HIM & Coding, Back-end, Clinicians, and CDI teams working together will help uncover the root cause of each denial and lay the groundwork for systemic elimination of the identified causes. Clinical coding quality and validation reasons necessitate collaboration between coders and physicians. Clinical Documentation Improvement (CDI) and coding teams must collaborate with physicians to gather clinical evidence to back up the appeal strategy. A regular cadence of meetings between coding and CDI staff can aid in improving coding quality and specificity.
Encourage a Learning Culture
Continuous learning is at the heart of an effective denials management program. To create organizational learning opportunities specific to the type of medical services provided, all stakeholders – front-end staff, clinicians, HIM, and coding personnel – must meet and collaborate.
Outsourcing as a strategy to address coding denials and accelerate the adoption of best practices for shifting focus from denial management to denial prevention can help healthcare organizations supplement their coding and denial management resources.
Healthcare providers must educate their employees about the insurance verification processes. Processing efficiently reduces the likelihood of denials and speeds up the cash flow cycle.
Read More: Advice on Revenue Cycle Management for Medical Practices.