Best Practices for Proactive Claims Denial Management

Claim denials are frustrating and costly for providers, patients, and payers. Learn how to recognize the most common causes so you can reduce their occurrence.

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Claim denials are an enormous drain on time and resources – for providers, payers, and financial services alike. Reducing denials helps providers deliver more transparent medical bills to patients, thereby increasing patient satisfaction and trust. The key is to be proactive in claims denial management, which involves addressing the root causes, establishing a strategy for management, and leveraging advanced technology for support.

Address the root causes for claim denials

There are many different reasons for claim denials — some more common than others. It’s important to analyze the most common reasons for claim denials experienced within your practice so you can specifically address those key areas by changing processes or providing relevant training. Here are some of the most frequent causes for a claim to be denied and ways to address them:

  • Claim ineligibility. At intake or scheduling, verify coverage and notify the patient if the maximum benefit hasn’t been met.
  • No prior authorizations. Ensure prior authorization has been obtained and the service or treatment is medically necessary. 
  • Incorrect or missing patient information. Double-check claim information (i.e., name, date of birth, payer, policy number, etc.) is correct before sending to coders.
  • Improper coding. Check coding for accuracy before submitting a claim, and be sure to stay up to date with new codes and coding regulations.
  • Improper claim submission. Most payers have different rules and regulations. Review payer requirements and rules prior to submitting a claim, as they can change over time.
  • Noncompliance. Stay current with HIPAA and other government regulations.
  • Missed filing deadline. Know the filing deadline, and submit claims promptly.

Payers also want to see reduced claim denials, as they are costly to resubmit. A payer-provider collaboration can help address them efficiently.


Establish a management strategy

After you understand the most frequent causes for claim denials, it’s important to have a strategy for addressing them going forward. The first step in that strategy should be to establish a team of experts from all areas of the medical practice, including providers, admissions, finance and billing, coding, compliance, and IT. With guidance from that group, your team can prioritize changes that will most affect the bottom line and start altering procedures and processes in those areas first.

Upskill or reskill people or departments prone to errors or those who need additional guidance to optimize their performance. Monitor your processes for inefficiencies and change, or create procedures that streamline practices and workflows. Keep tracking and monitoring these key changes to determine whether processes are being followed and the changes are yielding desired outcomes.

Leveraging advanced technology for support

Fortunately, technological advancements have made claims processing quicker, easier, and less prone to errors. The result? Fewer claim denials. An automated medical claims processing system can quickly and accurately verify patient information, ensuring claims are free of errors and filed before the deadline. Healthcare teams can rest assured they will remain current with changing billing requirements and policies.

There’s no doubt claim denials are costly to payers and providers — and detrimental to patient satisfaction. Although you can’t eliminate claim denials entirely, there are measures you can implement to reduce them. One of the most effective ways is to outsource your claims processing to an experienced revenue cycle management company, like Trubridge, that understands claims processing inside and out. Give us a call at 877-543-3635.