Three Tips to Manage Clinical Denials

By Giliane Poole, Senior Director, ARS, Receivables Management | Posted: 10/16/2017

A clinical denial is the denial of payment by an insurance payor on the basis of medical necessity, length of stay or level of care. Typically, clinical denials require an appeal on the part of the health care organization to achieve payment. Clinical denials can be difficult to manage; payors are looking for information specific to the care received by the patient and the need, or medical necessity. A clinician’s expertise is crucial here in order to resolve.

Of the major denial reasons, clinical denials such as medical necessity or no authorization account for the most revenue leakage in health care organizations. The trick is to know how to manage clinical denials.

Read our top three tips for managing clinical denials:

1. Educate your staff

Provide education and training to your staff. Once you pinpoint the root causes of denials, educate and train the team to target these areas and reduce denial recurrence. Track training progress in standardized reports native to online education systems to monitor individual productivity and error rates that inform management teams of on training progress. Important information to share as part of education and training includes patient accounting system data, 835 (payer remittance) data, and 837 (claims) data. If ongoing training is a challenge for your organization, consider subscribing to an education platform that updates its training content every few months.

2. Track payor requirement

Track payor requirements, which change often. Designate points of contact in each department within your revenue cycle to communicate payor changes to other areas when they occur. Update mapping tools periodically so they reflect the changes. If payor contact information – phone, fax numbers or email addresses – changes, post updates in a central location that all affected staff can access.

3. Outsource denials management

If managing staff education and frequent payor requirement changes seems daunting for your organization to manage, consider outsourcing clinical denials. Flexible staffing allows for scaling a team up or down based on your clinical denials backlog without disrupting your in-house billing staff. Find a partner offering deep, specialized clinical expertise in the areas where you experience denials the most. This will ensure the highest likelihood of success when dealing with the clinical appeals process.

Take control of your clinical denials and you’ll add revenue that is rightfully yours to the bottom line.