Dealing with Rejections and Denials

Finding the root issue of denials and rejections is essential to keeping a consistent cash flow for your practice. Many times, rejections and denials can be avoided through simple changes to daily processes.

Denials and Rejections — what’s the difference?

Before we get into ways to fix issues that cause rejections or denials, we need to know that there’s a difference between a rejection and a denial. A rejection is a front end scrub of the claim, usually before the claim makes it to the payer. You will typically receive a report back through your clearinghouse letting you know that some data is inaccurate and how to correct it. A denial is different in that a denial comes from the payer after a claim has processed. That claim will need to be corrected and refiled.

As a practice, our goal should be to fix any process that leads to a rejection or a denial. How do we do that?

Focus on Getting Registration Right

In the fast-paced world of physician’s offices or hospitals, data can easily be entered incorrectly. The danger with this is that even the smallest amount of incorrect information can cause a claim to reject or to deny.

A simple way to solve registration issues is to create a checklist of information that must be correct. Examples of information for a checklist are names, birth dates, policy and group numbers, and insurance cards. Ensuring the accuracy of this information can have a tremendous effect on the amount of rejections and denials your practice receives.

Leverage Your Clearinghouse

Another great resource in your pursuit of defeating denials and rejections is your clearinghouse. Ensure that your clearinghouse is setup to be able to receive real time data back from payers. If you use a billing company to review all of that information, strongly urge them to track and document that data in order to provide feedback. Your clearinghouse can give you insight on common issues and patterns of problems that need to be fixed to make sure claims go through as quickly as possible.

Troubleshoot the Issues

When trying to identify an issue in the medical industry know that one rejection or denial should be an eyebrow raiser, two of the same rejections or denials is a yellow flag, three or more of the same rejection or denial is a red flag and needs to be brought to someone’s attention. If an issue happens three or more time, work to identify the root of the issue. Is someone adding a hyphen in the Medicare Policy number that your system does not recognize? Does this patient have an HMO? Are policy numbers being transposed? Does this patient not have benefits for this specialty?

When you see a pattern, train your team on what to do to avoid getting a denial or rejection for the issue.

Need help with your rejections or denials? Legacy Consulting Services can help. Contact us and let us know how we can add value to you.


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