Resources for Providers, Billing and Administrative Staff

Denial Management - Definition, Goals and Challenges

Denial Management is the process of systematically investigating each denial, performing root cause analysis of why each claim was denied, analyzing denial trends to uncover a trend by one or more insurance carriers,and redesigning or re-engineering the process to prevent or reduce the risk of future claim denials.

Many physician practices forgo thousands of dollars annually in revenue through denied healthcare claims. These denials typically stem from a lack of strong denial management policies and procedures.

Essentially, you want to lessen the number of denials by seeking the root cause for it as well as the coded cause. Every instance where no payment or lower than expected payment occurs must be investigated.Doing this is an essential part of optimizing your revenue cycle.

These numbers paint a clear reason as to why denial management is an imperative process for physician practices:

• The average claim denial rate across the healthcare industry is between 5% and 10%.
• Commercial and public payers deny about one in every 10 submitted claims.
• Gross charges denied by payers have increased to 15% to 20% of the nominal value of all claims submitted.
• An estimated 90% of denials are preventable. 
• Up to 65% of denied claims are never resubmitted.

An estimated two-thirds of all denied claims are recoverable.

 

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What Is a Controlled Substance?

Prescription drugs are those drugs that are prescribed by a provider for a specific person and bought at a pharmacy. These are regulated by FDA. Prescription drugs are classified into two categories:

1. Non-controlled prescription drugs
2. Controlled prescription drugs

Non-controlled drugs are prescribed to treat medical conditions such as high blood pressure, diabetes, and bacterial infections. Such prescriptions are not subject to some of the same limitations as controlled substance prescriptions.

Controlled substances are drugs or medications (whether prescription or illicit) considered to have the highest misuse and use disorder potential and therefore have the strictest regulation and prescription requirements on a federal and state levels. They are regulated by the Controlled Substance Act (CSA) which was enacted as part of the Comprehensive Drug Abuse Prevention and Control Act of 1970. To prescribe controlled substance medication, a clinician must have a DEA (Drug Enforcement Administration) license; to fill a prescription, a pharmacist must also have a controlled substance license.

 

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What is EHR?

EHR Definition

An Electronic Health Record (EHR) is an electronic or digital version of a patient’s traditional paper-based chart and offers a comprehensive, real-time and patient centered view of a patient’s medical history maintained by one or more authorized providers over time to authorized set of users. EHRs include all of the key administrative clinical data relevant to that persons care under one of more authorized providers, including demographics, progress notes, allergies, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports, etc.

 

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What is Electronic Medical Record (EMR) System?

EMR System is an integrated set of interoperable technology components including EMR Software, Practice Management Software, ePrescription, Dashboards, telemedicine, interfaces to labs and clearinghouses, workflow tools, patient portal, etc. - all working seamlessly to help healthcare providers improve patient care, stay compliant and reduce medical costs. EMR systems replace traditional paper-based charts and manual workflows with digital files and electronic transmissions in the physician practice and offer a comprehensive view of a patient’s medical history.

EMR Systems include “all of the key administrative clinical data relevant to that person’s care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports".  It is created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization". 

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What is Medical Billing?

Medical billing is the process by which healthcare providers create and submit claims to insurance companies, referred to as payers, to receive reimbursement for services provided to patients. Many claims that are denied due to including missing or incorrect data, duplicate or late submissions, improper or outdated CPT or ICD-10 codes, lack of documentation or prior authorization, and other reasons can be corrected and appealed.

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