Introduction
As healthcare systems and providers continue to navigate the changing healthcare environment, payers are increasingly important partners in improving patient outcomes and reducing costs. However, due to the complexity of health claims adjudication, it can be challenging for payers and providers to work together seamlessly. This can lead to delays in claim payments or denials that negatively impact both organizations. In fact, according to some estimates, only 20 percent of provider reimbursement requests are paid accurately on initial submission (and even fewer receive a final resolution within 30 days). These statistics highlight how much work still needs to be done to foster communication between payers and providers so that they can resolve payment disputes efficiently while eliminating fraud and abuse.”
Denial management
Denial management is a shared responsibility between providers and payers. Both parties need to work together to resolve denials, but there are steps you can take on your own to improve the process.
- Communicate clearly with your patients about what they need to do when they receive a denial notification for their claims to be paid correctly.
- If you’re using electronic health records (EHRs), educate staff members on how they should enter data into the system so that it’s accurate and complete enough for proper processing by insurers or other payers.
Payer-Provider Communication Strategies
It’s important to note that providers should be proactive in communicating with payers. This includes being clear and concise in their communications, using the right communication channels, being aware of payer policies and procedures, and understanding key payer communication policies.
In addition to these measures, providers should make sure they have a plan for addressing denials before they happen. To do this effectively:
- Create a standard operating procedure for handling denials (e.g., email format)
- Develop guidelines for dealing with each type of denial (e.g., “denial reason X” means “please resubmit”)
Create a clear process for communicating with payers (e.g., via phone, email, fax) and make sure staff are aware of it
Develop a plan for assessing and reducing denials (e.g., deny-to-pay ratio)
The last step is to have a plan for dealing with denials. The plan should include guidelines for dealing with each type of denial, create a clear process for communicating with payers and make sure staff are aware of it, develop a standard operating procedure for handling denials (e.g., email format), and assess whether the plan needs to be updated or changed based on new information from payers.
Fostering Communication Between Payers and Providers for Denial Resolution
To help you get started, we’ve outlined some of the most important points to keep in mind.
- Proactive communication with payers is key: To successfully move through the denial management process and avoid unnecessary delays in reimbursement, providers need to be proactive about communicating with their payers. This means that they should engage in regular conversations with their third-party administrators (TPAs) and other stakeholders at every step of the way–not just when there’s an issue or complaint that needs addressing.
- Payers are often unaware of clinical information: When providers do not communicate clinical details related to a claim, it can lead to errors on behalf of both parties involved because neither party has all of the necessary information needed for processing claims accurately or efficiently.
Approaches to Improving the Process
Providers should be prepared to discuss the reasons for a denial.
Providers should be prepared to discuss the medical necessity of a service.
Providers should be prepared to discuss the patient’s clinical condition.
Providers should be prepared to discuss the clinical documentation supporting the claim, including:
- Patient’s diagnosis(ES)
- Treatment plan/procedure performed or prescribed by a provider
- Medical records and/or reports from other providers (if applicable)
Solutions for Denial Resolution
- Provide accurate and timely information. The first step in resolving a denial is providing the payer with complete, accurate information. This can be accomplished by having an established working relationship with the payer, ensuring your claims comply with their requirements, and using the right technology.
- Establish a good working relationship with payers. It’s important to establish a good working relationship with the insurance companies that cover your patients so that you can get more information about why they denied a claim or request reimbursement from them when needed.
- Ensure your claims comply with payer requirements before submitting them for payment processing (e-claims) or billing services (paper claims). For example: if you have an EHR system that automatically generates electronic health records (EHR), make sure it does so according to all applicable federal standards set forth by HIPAA regulations; similarly, if you use paper-based systems make sure those comply as well such as including all necessary patient demographic data such as names address phone numbers, etc., plus any required signatures from physicians/nurses, etc.. These types of things might seem trivial but they could mean big trouble later down the line should something go wrong!
The Sooner you engage with your payers, the better
It’s important to have a plan in place for dealing with denials. This can include developing an internal process for escalating issues that remain unresolved after contacting the payer or working with a third-party vendor that specializes in helping providers manage their reimbursement programs. If you’re not sure how best to proceed when faced with a denial from one of your insurers, ask them directly what steps need to be taken next–and keep asking until they give you an answer! It’s also wise to understand the policies of each insurer before submitting claims so that there are no surprises later on down the road when it comes time for payment processing and resolution (or lack thereof).
Conclusion
In conclusion, there are many ways to improve the process of denial management. We have outlined some of the most effective strategies for communicating with payers and providers in this article. We hope that by reading this post, you have gained insight into how you can build better relationships with those who are important to your business success–and maybe even learned a thing or two about yourself along the way!
