Creating an Effective Strategy to Address Clinical and Coding Denials 17 Jan 2023

Clinical and Coding Denials

A significant portion of the income for your practice comes from medical billing and coding denials. Refusals of claims might result in severe financial loss. Denied claims can cost you money if they are not swiftly handled since they prolong the revenue cycle and interrupt cash flow. The burden is further increased by the expense of processing each rejected claim. Are you dealing with a lot of denials and seeking a reliable plan to handle them? It’s critical to comprehend the reasons behind claim denials so that you may come up with a plan to stop more denials and prevent income loss for your practice.

The procedure used by healthcare systems in the United States and across the world to track patient income, from their initial appointment or interaction with the healthcare system to their final payment of a debt, is known as revenue cycle management (RCM). It is a typical component of healthcare management.

Are you curious as to what denial management in medical billing entails? Denial management, on the other hand, is a phrase used in medical billing to describe the procedure for dealing with insurance company denials. Although it would appear to be a simple process, it cannot be so simple for a number of reasons. Every time you see a healthcare professional, medical coding takes place. The healthcare professional looks over your complaint and medical background determine what’s wrong and how to treat you, and records your appointment. Not only is that paperwork the patient’s continuous record, but it also serves as the basis for the healthcare provider’s payment.

With HIPAA and other rules governing how healthcare providers should handle personal information, denial management has grown more challenging. But expert medical billing businesses are aware of how to handle it.

Different Kinds of Denials:

  • Soft Denials – A soft denial is intended to be merely transitory. It may be paid if the claim is revised and/or further information is supplied.
  • Hard Denials – It is unstoppable. Revenue has been lost since it cannot be corrected or recovered.

Developing an effective strategy for dealing with Clinical and Coding Denials

Healthcare practitioners are an essential part of society who must focus only on their patients’ needs. However, claim denials frequently deflect attention since they are a major source of financial loss for medical practices. Coding-related rejections are a substantial source of rejections, resulting in cash loss for healthcare institutions and, unwittingly, lowering healthcare quality. As a result, monitoring medical bills and preventing coding denials are critical.

This requires the development of an efficient approach for understanding and addressing gaps in medical billing and coding denials through reliable appeals procedures in order to avoid income loss. A method for successfully disputing medical billing and code denials. To reduce the avoidable reasons for coding denials, medical institutions and the team must implement an effective plan.

  • Collaboration Across Organizations

Collaboration between physicians and coders is required to overcome rejections caused by poor clinical coding and validation. A collaborative effort between clinicians, coding teams, and Clinical Documentation Improvement (CDI) will generate clinical evidence to support the appeal approach.

  • Creating a cross-functional team

The facility’s many teams must collaborate to handle rejections, implement systemic controls, or refrain from doing actions that can lead to denials.

  • Streamline Appeals

The rejections management team must standardize appeals in order to obtain the essential data from the relevant functions; timely appeal filing is required to boost success rates. Healthcare organizations can also outsource their medical billing and denials management operations to improve clinical coding quality and the time it takes to file appeals.

  • Success tales should be archived.

Learn from successful appeals and preserve them as cases for future reference. Check the clinical validity and coding accuracy for coding-related rejections using additional recommendations and resources from the AMA and AHA.

  • Instil a learning culture in your organization.

To create organizational learning opportunities that are specific to the kind of medical services provided, all stakeholders, including front-end staff, physicians, HIM, and coding personnel, must collaborate.

Reasons for Denying Claims:

Receiving a claim denial causes a practice great inconvenience. It not only causes a delay in your payments but also slows down office operations. It’s critical to comprehend the potential causes of your growing number of refused claims. We wish to assist as a medical coding firm ourselves. The top five reasons your claims are being rejected are shown below.

  • You waited too long.

The most frequent cause of claim denial is that it was submitted after the deadline. There is a large window of time available for claims to be made, so this could surprise some doctors. In reality, doctors often have 60 to 90 days to submit a claim to insurance. The moment the service is provided, time begins to run out.

Why aren’t these claims being submitted in a timely manner? Arrangement and volume of documents. Claims multiply quickly. To correctly handle it might be daunting. Your claims, coding, and billing may be handled by a medical coding business, which can greatly reduce your paperwork.

  • Poor Coding

Bad coding is a widespread problem. Thanks to the adoption of ICD-10, this is true than ever. Several factors might cause ICD-10 codes to be incorrect. It’s possible that the new codes differ from the previous ones used for your most often procedures. ICD-10 codes frequently lack complete writing.

Some ICD-10 codes have entirely different meanings than they had in ICD-9. Your claims might be rejected if your codes are not only present but also complete, appropriate, and accurate.

  • Patient Information

Insurance companies cannot process claims properly if the patient information is erroneously entered. It’s a little, but an all-too-common error that many doctors make. Whether their name is misspelled, their birthdate is wrong, or their subscriber number is absent, it is practically hard for an insurance company to connect the claim to the actual patient. Every piece of information helps to link a claim to a patient. The transaction cannot be completed if it cannot be matched.

  • Permission

Preauthorization is required for most insurance plans, yet it is still one of the most common reasons claims are refused. Furthermore, authorization is only granted for a limited period. An insurance company usually offers physicians a set number of appointments or days before their authorization expires. If care is provided after these dates, the physician will not be compensated.

  • Referrals

This one is challenging and intricate. Many insurance firms have implemented a referral system. In other words, physicians cannot perform a service unless the patient has been referred by their primary care physician. If a service and claim are submitted prior to the primary care physician’s referral, the claim will be denied.

  • Ineffective claim denial management

Denial management is a critical phase in revenue cycle management and must be handled with care. The goal of a Denial Management Process is to evaluate every underpaid claim, identify a trend by one or more insurance carriers, and appeal the denial correctly according to the provider contract’s appeals process. Employ a competent team capable of resubmitting refused claims, understanding the causes for denials, and developing an iterative approach to prevent future denials due to the same concerns.

  • Patient-Centeredness

Your primary obligation as a healthcare organization is patient care and satisfaction. According to research, patient-centered treatment can improve other crucial outcomes. Patients who report pleasant experiences have higher trust in their clinicians and are less likely to transfer physicians, allowing for more continuity of care.

Technically, patients simply respond better. Clarify patient responsibility, provide flexible payment options, and develop a customer service staff that communicates with your patients on a regular basis.

  • Personnel or Front Desk Issues

Personnel or Front Desk-related Inefficiencies or incorrect training of the reception desk and billing department generate problems. Ensure that front-desk staff receives sufficient training in order to correctly record data while treating patients with care and empathy. Entrust your billing process to trained and certified personnel who can file bills and immediately follow up.

  • Procedures that are incomplete or unbilled

Incorrect coding leads to poor patient care and payment issues. Physicians must be aware of all billable procedures and ensure that small treatments are not left unreported. Educating physicians on billable treatments reduce the number of incomplete and unbilled operations while increasing income. After a thorough conversation with the physicians, a skilled medical coder can generally detect income loss owing to unbilled operations.

  • Claims that are incomplete, unbilled, or erroneous

More income is lost due to incomplete, unbilled, or erroneous claims than any other reason. Furthermore, false and exaggerated assertions might harm the company’s performance and image. By comparing reports of patient appointments, operations performed, and claims submitted, these claims can be detected.

Resubmit Claims Within the Allotted Time

Follow your rejection management guide, review the insurer’s denial message, and double-check your internal paperwork. Contact the patient if required. Keep in mind that most insurers have time limits for resubmitting claims; the last thing you want is to be refused payment due to late submission.

Investigate the Denials

The simplest way to deal with claim denial is to avoid it in the first place. According to industry sources, the normal denial rate for practices is between 7 and 10%, although it should be between 4% and 2%. Preventive denial evaluation is a root cause study of all denials received in order to reduce the denial rate in the future.

Why is Medical Coding Required?

The healthcare income stream is built on documentation of what was learned, decided, and performed.

A patient’s diagnosis, test findings, and treatment must be documented not just for payment but also to ensure high-quality care in future visits. Personal health information accompanies a patient through future complaints and treatments, and it must be easily comprehended. This is especially essential given the hundreds of millions of visits, operations, and hospitalizations that occur in the United States each year.

Code Types in Use

Medical coding is used all throughout the world, with the International Classification of Diseases (ICD) being used by the majority of countries. The World Health Organization maintains ICD and each member nation modifies it to meet its own needs. There are six official HIPAA-mandated code sets in the United States that serve distinct requirements.

Why is Medical Coding Essential in Revenue Cycle Management?

Medical coding is done for research and statistical purposes because having standardized data enables more effective study, inquiry, and data monitoring. The patient is taken to the hospital, where physicians treat him. We don’t know how to keep costs under control while yet providing high-quality treatment to people.

So, when we undertake medical coding, we will be aware of information like as. Why are so many people sick, and what are the most frequent diseases?

Once they have standard consistent data (statistics), the government can make appropriate decisions to improve patient healthcare and prevent certain diseases. As a result, coding medical records is critical.

As we all know, medical insurance covers practically all medical bills in the United States of America. The medical coding technique is used to bill insurance companies in order to repay payments for healthcare services rendered while also maintaining consistency criteria.

The following guidelines serve as the foundation for a good denial management plan.

  • ¬†Identify – Locate and resolve the issues that cause insurers to deny claims.
  • Manage – Sort rejections by reason, source, cause, and other distinguishing criteria.
  • Monitor – Keep track of rejections, and audit workers’ efforts, and provide the necessary tools, technology, and resources.
  • Prevent – Collaborate with patients, physicians, and others to appeal and overcome erroneous rejections.

Put a stop to Coding Denials.

If you’re losing money despite hardworking workers and cutting-edge equipment, it’s an indication that you need an experienced and dependable organization like Velan. We are a ‘Phoenix’ that delivers accurate and perfect medical coding and billing services.

Velan’s skilled medical coders assist clients in reducing the time-consuming processes of monitoring and reporting services so that every patient cared for in your medical institution changes into a paying bill and is not refused due to minor errors.

Victor Bala

Medical & coding

About the Author:

Victor has over a decade of experience in delivering revenue cycle management services to the US healthcare providers. He has a proven track record of accelerating revenue collection by streamlining the billing, coding and AR processes. His team at Velan has been delivering revenue cycle management cycle, appointment scheduling, pre-authorization and credentialing services to physicians, group practices, and hospitals. He can be reached at


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