Denial Management in the Time of Pandemic

Health crises such as COVID-19 pandemic are putting a strain in the healthcare system. In the lens of health insurance, policy cancellations add a different level of burden. While the government has support implementations such as Coronavirus Aid, Relief and Economic Security Act which helps fund businesses for business continuity and retain employees, there is still an expected increase in policy cancellations as a result of unemployment and the overall economic downturn.  It is also uncertain as to whether the government will provide relief to the insurance industry.

Despite the increased insurance cancellations, health insurance companies are taking the toll on paying for expensive tests and treatments for those policyholders that have COVID-19 coverage. According to American Academy of Actuaries, insurance companies without large cash reserves could have problems because expenses related to COVID-19 treatment are expensive and there is a widespread waiving of cost sharing. It is then crucial for insurance companies to have accurate medical coding and billing processes to avoid mistagging insurance coverage and ensuring that cash flow is managed correctly.

Although the US administration declared a national emergency by granting HHS authority to waive certain Medicare, Medicaid and CHIP policies, pandemics are a phenomenon that not all health insurance companies have prepared for. There will be confusions over what the blanket waivers do insurance policies cover in an attempt to manage health crises with a finite amount of resources.

To track the spread of coronavirus and get paid for testing and treatments, having accurate billing and coding processes are the key in helping providers in overcoming the challenges of a pandemic now and in the future. Also, having accurately coded medical procedures streamlines communication across the health system and reduces administrative rework decreasing costs at a time especially with the scarcity of resources. Prior to the pandemic, health insurance companies are already facing high volume of claims and billing errors. When the economy reopens, there will be a definite surge in medical claims and billing.

But since this is a new health crisis that health insurance companies are facing, some treatments and procedures will fall under the denial management system.

How, then, can you effectively manage denial claims in times of crisis?

Understand how and why claims are denied at the first place

Knowing why claims were denied is important in streamlining your process to maximize your collections revenue and preventing future denied claims from happening. Since most if not all of the patients are knowledgeable about the insurance denial system, it is your job to educate them on how they can solve the issue. But you can only do so if you and your team members are aware of the reasons for denied claims. This will also give you an avenue to create action plans on organizing and creating a system in place to keep track of your denials. 

Many health insurance companies and hospitals are adopting tools and technologies in assisting them in tracking the ‘when’ and ‘why’ the claims are being lost in the shuffle. This will help your company in managing denials and keeping an eye on which ones still need attention in the best way to maximize denial collections revenue. Keeping track of denied claims will help you see which areas in your denial management process are working and which need further support. Documenting both wins and losses, in regards to your unpaid claims helps in improving the efficiency of your organization and sticking close to the analytics in your strategy in denial management.

Identifying common denial trends and updates in medical codes

Being aware of the common denials is a crucial component of establishing an effective denial management process. Although each health organization may have a unique list, there are top causes for coding and billing denials common to every health insurance company which are; Coordination of Benefits, PIP Applications, Accident Details, Pre-existing Conditions, Name Misspellings and new emerging illness and diseases.

These denials may seem like a small problem initially but with continued tracking and analysis it may reveal larger issues within your health insurance company. Creating a system in the denial management strategy of your organization helps ensure that these problems are addressed on the set and also creates foresight for trends five years from now. Plan ahead, and you may see your list of common denials start to lessen. 

Being updated with the new codes in enabling COVID-19 tracking and billing can help in capturing testing and treatment claims. CDC announced in March that it has added the new International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) emergency code created by the World Health Organization earlier this year. According to official guidance from the CDC, health insurance providers should only use U07.1 to document a confirmed diagnosis of COVID-19 as documented by the provider, per documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result. Being aware of these updates and codes also helps in decreasing denied claims.

Outsourcing denial management process and team

It is then very crucial for health insurance companies to minimize their operational cost and secure accurate medical coding and billing processes to avoid mistagging of insurance coverage and making sure that cash flow is managed correctly especially in the midst of the recovery phase caused by the pandemic. Having a team of reliable and experienced medical coders, billers and claims processors who are crucial to accurately translate patient data into alphanumeric codes and properly tag which treatment and tests are covered by the insurance plan to make sure that the medical expenses are accounted for correctly and accurately. 

Partnering with a reputable & trusted outsourcing company that specializes in Revenue Cycle Management services and has expertise in denial management. Top denial management providers build great teams of highly trained billers and coders that are working with, negotiating and navigating the complexities of the insurance system. By outsourcing your denial management tasks, you’ll have more time to focus on the core areas of your business that require your attention. When choosing which outsourced company to partner with, there are two questions you should ask:

1. Will they ensure exceeding customer satisfaction?
2. Will their claims management assistance refute denied claims and increase cash flow?

Expanding other non-clinical related concerns such as medical billing, coding, claims and health insurance processing by partnering with an outsourcing company that is an expert in the Revenue Cycle Management (RCM) process who can provide these extended services virtually can be one of your key weapons in keeping your healthcare business afloat. This team can help in accounts receivable management including follow-ups of unpaid claims and resolution of denials. They can also take care of filing claims to health insurance carriers, post payments received, send patient statements and stay updated with the trends and changes that may affect client’s reimbursements. This results in >95% claims accuracy, 1 hour turnaround time and minimal to none denied claims by getting it right the first time.

At Infinit-O Global, we build great teams of medical billers, medical coders, clinical and medical abstractors that resolve claims denied by medical insurance carriers, stay up-to-date with the changes that affect client’s reimbursements and understand how the medical insurance industry works. Our aim is to create long lasting partnerships and endless opportunities for your business to grow on top of saving at least 70% on operational cost. We render a strong combination of business consultancy, process optimization, and outsourced services; all utilizing the latest technology to provide excellent value for our clients. We are ISO-certified, HIPAA– and GDPR-compliant, so your company and data are safe with us.

Infinit-O Global’s aim is to create long lasting partnerships and endless opportunities for your institution to grow while managing the sudden demand for healthcare. We render a strong understanding in medical review and analyzing clinical abstractors for health institution consultancy, process optimization, Revenue Cycle Management (RCM) process and outsourced healthcare services; all utilizing the latest technology to provide excellent value for our clients.

Infinit-O is the trusted customer-centric and sustainable leader in Business Process Optimization to Small and Medium businesses in the Financial Services, Healthcare and Technology sectors by delivering continuous improvement through technology, data and people.

Let’s work together to Build a Great Denials Management Team.