Denial Management Solutions: 1 Great, 1 So-So and 1 Awful Option

New Denial Management Solutions are making a major, positive impact on insurance reimbursement revenue for hospitals and healthcare practices.

The Money Game

Insurance companies have always been and always will be in the business of making money. And ever since Obamacare was just a speck of an idea being initiated by the President, carriers nationwide have been nervously and feverishly plotting all the ways they would protect themselves from lower profit margins and earnings. Their answer: dozens of new ways to avoid paying claims.   


Medical claim denials are a stress inducing hassle- the constant back and forth between insurance carriers and hospitals can cause friction and cost your organization a lot of money. Whether it’s duplicate claims, required patient information that’s missing, or expirations, these denials are enough to make healthcare and hospital administrators pull their hair out (what’s left of it anyway!).

But you can combat these claim denial challenges with new services designed to overcome denied claims. 

Keeping up with the constant influx of claim denials is labor intensive, time consuming, and prevents your patient accounting staff from focusing on more profitable work.

As insurance companies find creative ways and loopholes to deny your reimbursements, you could be losing or waiting (not so patiently) for hundreds of thousands or even millions of dollars in owed revenue. That’s why many hospitals are implementing solutions and strategies to prevent or manage denied claims. Denial management solutions are helping CFOs and healthcare leadership regain control of the reimbursement dynamic and get more monthly claim revenue in the door.  

There are no shortage of reasons insurance companies can deny your claim but a recent Healthcare Finance News report suggests that most denials happen for the same reasons, time and time again. Here are the top 5 reasons:

  • Claim lacks information

  • Duplicate claims have been submitted

  • Insurance eligibility is expired

  • Claim not covered by insurance provider

  • Claim submission time limit expired

Other common reasons for denials include:

  • Coordination of Benefits (COB)

  • Accident details

  • PIP (Personal Injury Protection)

  • Preexisting conditions 

With an ever-increasing number of reasons you can be denied the money owed to you for services rendered, managing this critical piece of your revenue cycle can’t be overlooked.  More precisely, it demands immediate attention and an action plan for resolution.


3 Ways You Can Attack Denial Management

Option 1 (Recommended!):

Hire an expert 3rd party BPO Company (Business Process Outsourcing) who specializes in revenue cycle services, with expertise in denial management. Healthcare BPO companies have two main goals:

  1. get you more money from patients and payers

  2. give exceptional customer service so your patients are happy, satisfied and come back to your hospital or practice the next time they need medical attention.

These 3rd party vendors have specialized teams that are highly trained in working with, negotiating, and navigating the complexities of the insurance system. Instead of relying on your in-house patient financial services team to successfully master the art of insurance negotiations, outsource this job to a revenue cycle services vendor who only gets paid if they get you money (the only acceptable and reputable payment structure by the way).  

***Option 1 Bonus:

Revenue Cycle Services vendors or healthcare BPO Companies are experts in much more than pursuing denial revenue.  They can take over all of your revenue cycle activities from patient and payer claims to statement generation and payment processing.  It’s a full-service solution so if you’re not already outsourcing RCM to a BPO, you should consider it as a very viable option for reducing administrative costs and increasing monthly revenue.

Option 2 (This can get tricky but it’s better than nothing):

Ask your internal patient accounting team to devote more time to denials. The tricky part is that you may need to invest some serious time in training this team to do so.  A lot more goes into managing denials than just picking up the phone and calling the insurance carrier.  Furthermore, your patient financial services team already has their hands full with the other revenue cycle activities (hint- see Option 1 Bonus above).  

Unless you’re planning to expand your patient financial services staff, adding training and more responsibilities to their plate may dilute their focus and ability to maintain the productivity required to meet your patient pay and payer pay revenue goals.

Option 3 (And really, this isn’t an option):

DO NOTHING. Denied claims won’t end the world. They might put a major financial hurting on your organization but life will go on.  But with such readily available denial management services at your fingertips, why just accept this growing burden?  You’re a respected leader - you didn’t get to this position of knowledge and responsibility by luck.  No, you’re here because you make strong, influential decisions that positively impact the well-being of your team and its future.  Doing nothing is never going to be an option that makes sense, or gives you peace of mind.  So with that being said, please see Option 1.  Hiring an expert to handle this “dirty work” just makes sense, financially, strategically, and logically.

Determine If You Need Denial Management Services