Welcome! We’re glad you’re here and following along with our Denial Madness Tournament Bracket. We will be creating new posts every time we reveal the next round of preventable denials. We’ve gotten through the first round of our Denial Madness 2023 Tournament Bracket. We’ve reduced our top sixteen denials down to eight.
There are many variables to consider when determining how to prevent denials. We’re going to start answering some of those questions. Which denial category should you work on first to prevent denials and where will the greatest impact be?
Our approach during our Denial Madness 2023 Tournament Bracket is to make our decisions at a general level of understanding. We know that there may be specific instances in your organization where it might make sense to choose differently.
Like a basketball tournament with 64 teams, we understand that matchups play a role in how you make your decisions. You might make a different decision if the matchup is different. In our Denial Madness 2023 Tournament Bracket, we are making our decisions based on the matchups that we initially set. We might make different decisions if the initial bracket was different.
Okay, let’s start the big reveal!
Bracket One: Duplicate and Overlap Denials vs Other Facility Overlap
There are many tools that can be put in place to prevent duplicate denials (conflicting claims, consecutive work queues, reduced rebilling etc). This gives us more control than “other facility overlap” denials where we can’t control if another facility does not discharge a patient accurately. Winner: Duplicate and Overlap Denials.
Bracket Two: Authorization and Pre-certification Denials vs Exceeds Frequency
Since all payers have listings of which services require authorizations, working on reducing your authorization and pre-certification denials can be a more efficient practice. Building edits when authorization numbers are missing and communicate denial information with other departments can be other ways to help prevent these denials. Winner: Authorization and Pre-Certification Denials.
Bracket Three: Building and CCI Edits vs Eligibility and Coverage Issues
If possible, we recommend that you implement eligibility and coverage discovery tools in your organization. With these tools in place, you can significantly reduce eligibility and coverage related denials. We realize that an eligibility tool can be costly and difficult to implement, but denials cost even more. There are many options and in most cases they are easy to integrate. If you’d like recommendations, let us know. Winner: Eligibility and Coverage Issues.
Bracket Four: Billing Related - Edit Review Needed Denials vs Additional Info Requested from Provider
This one might have you asking, “what is edit review needed?”. This denial is unique to the technology platform that OS inc. customers utilize. It identifies opportunities where a denial can be prevented by implementing an edit or change routine in your clearinghouse or EHR. An example of this denial would be a CPT modifier mismatch – your claim scrubber should flag this so you can get paid on first submission. Since our goal is to always prevent denials, getting edits into the clearinghouse to prevent denials is always a great solution. Winner: Billing Related – Edit Review Needed.
Bracket Five: Other and Medical Necessity
Our other category is a combination of different categories where the total numbers of denials don’t add up enough to get into our top 15 list. With our denial analytics platform, we do have the capability to drill down into the detail of this category, but "other" isn’t the first area that we focus on. We would prefer to utilize the clearinghouses and patient accounting systems to make sure that they are set up correctly to prevent medical necessity denials. Most of these systems have the capability to help prevent this type of denial by using edits and then communicating back to departments/physicians when there are documentation issues to further prevent write offs for medical necessity. Winner: Medical Necessity.
Bracket Six: Additional Info Requested - Patient vs Timely Filing
We hope this one is obvious. This is a simple case of knowing and not knowing. We always know when a claim is nearing timely filing. It’s important to act on those to prevent them from hitting a timely filing denial. In the case of insurance companies requesting more information from the patient, we don’t know that additional information is required until the payer tells us. From a denial prevention perspective there’s little we can do. Winner: Timely Filing.
Bracket Seven: Coordination of Benefits (COB) vs Coding Denials
This is another case where you can leverage a tool to help create an efficiency in your denial management process. Utilizing an insurance discovery tool is a great way to identify COB information on a claim to help prevent this type of denial. Coding denials are less preventable because we may not know or be aware of the background coding rules for a specific payer. Unfortunately, we can’t find these out until after we submit a bill (argh!). Winner: Coordination of Benefits (COB).
Bracket Eight: Benefits Exhausted vs Provider Enrollment
Every provider organization should have a matrix to track the credentialing of their providers with all their payers. If a provider is not credentialed, a hold should be placed on that provider to prevent any claims from being sent to the payer. This is an easy win from a preventable denial perspective. If this is a denial category that is high for your organization, it might be time to review your credentialing process to identify where things might be getting stalled. Winner: Provider Enrollment.
Look for our next update coming soon. If you have any questions about denials and would like to be connected to one of OS inc’s experts, contact us here. If you have some thoughts on our denial selections, let us know as well. This is an art, not a science and we can all learn from each other.
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