Denials Management

Do you know what your denial rate is? Most healthcare providers should be targeting a denial rate of less than 5 percent. For certain denial types, such as timely filing denials, the rate should be 0 percent. Yet according to the American Academy of Family Physicians (AAFP), the average practice denial rate is between 5 and 10 percent. The Government Accountability Office (GAO) estimates that as many as 25 percent of governmental payer claims are denied. The cost for a practice to pursue a single denied claim can easily exceed $100. Despite the avoidable nature of many denials, their frequency, and high cost, many practices struggle with denials.

 

So why are denials so challenging for healthcare providers?
In smaller practices, the employee handling denials may wear many other hats. When a patient is standing in front of you, or the phone is ringing, denials may take a back seat to other, more pressing issues. This can quickly become costly. Denials can be a sticky issue because each payer has its own rules, and those rules change. Payers typically won’t disclose the logic behind their systems that result in denied claims. In fact, one of the top 3 reasons claims are denied by health insurers is that the codes and modifiers used did no conform with the plan’s rules.
 

The experts at THG Consulting can help, because

• Our team can quickly dig into rules and guidelines to help your practice code for success.

• We bring payer-specific expertise you may not have internally.

• We achieve economies of scale, because we work with denials across a wide range of providers and insurers

• Payer language can be confusing. We know the ins and outs of why your claims are getting denied, and what those payer codes and remarks mean.