Ethos Infoways

Denial Management

Denial rates vary widely depending on physician specialty. Denials for some specialties, such as obstetrics and gynecology, can be as high as 20 percent. Denials for primary care practices can be 10 percent or below. As a rule of thumb, a denial rate of 15 percent affects practice profitability.

Obtaining an accurate reflection of denials for a multispecialty practice can be challenging. “The denial rate for a multispecialty group practice may be 5 percent, but that overall rate may include a 20 percent denial rate for obstetrics and a rate of 1 percent for family practice. You need to look at denial rates by type of specialty. We segregate denial rates for primary care [family practice and internal medicine] from those for specialties that have potentially higher denial rates.

When the denial rate is high, it should be looked at immediately. We address two areas of denials: why they are occurring and preventing them in the first place.

At Ethos Infoways Denial Management is not introduced to just resubmitting a claim. We have a team of experts who analyze the reason for denial, track the most common denominators and systematically work on identifying and eliminating weak links. Our collections and denial management support helped practices reduce claims rejection drastically

Information verification before the bill goes out the door:

The most common reason for denials is incorrect information: ID numbers are incorrect, CPT codes or modifiers are not put in the right place, names are spelled incorrectly, or names don't match what is printed on the patient’s insurance card.
We make sure to verify all these details before claims are sent out.

Focus on reasons of denials:

We understand the regulations around billing to make sure it is being done correctly in the first place. The abundance of managed care plans, stricter Medicare and Medicaid regulations, and the need for frequent authorizations for payment can increase denial rates if not proactively managed.
Identifying denials associated with billing processes and drilling into the reasons allows clinics to error-proof processes, decreasing future denials.

Prompt follow up on denied claim:

Depending on the denial reason, we resubmit claims way before you even get the paper denial through the mail. By calling the insurance company and finding out the denial reason instead of waiting to receive the denial in the mail, we correct the reason the claim was denied.
Resubmitting the claim few days earlier than waiting for the denial in the mail will definitely shorten the turnaround time for your payment. The bottom line is getting a head start on your denials to get the healthcare claims process moving again.

We don't assume the insurance company is right:

We monitor unclaimed revenue reports and appeal denials when warranted. The reality is the insurance company may not be correct issuing denials, the insurer’s systems may not be up to date. If we believe your claim is incorrect based on your agreement, then we appeal the claim.
Our team also reverts back to the practice with changes in the health insurance billing guidelines – as in, revising billed amounts – to achieve maximum value on contracted payments.

Internal Process:

Building rapport with the insurance representatives in an AR Follow-up, while calling the insurance company is important. This would help us find solutions for cases where the claims have been denied consistently for various reasons including global issues. In some instances, the representatives might even turn hostile and might not even reveal much of the required information, which could prove vital in proceeding further on the claims and we have to be very careful in handling situations like this.
Our AR representatives have strong interpersonal & communication skills and are able to make the insurance representatives feel comfortable and make the call easy going.

When do we call patients?

When there is no insurance coverage information found in the demographics section of the patient's account.
When the insurance company has denied a claim stating that the patient is not eligible for coverage at the time of service, where the date of service could be prior to the effective date or after the termination date of patient's insurance coverage.
When any personal info like patient's name, social security number, date of birth, address etc is found to be incorrect in the patient's account

Denial Management

Information verification before the bill goes out the door:

Focus on reasons of denials:

Prompt follow up on denied claim:

We don't assume the insurance company is right:

Internal Process:

When do we call patients?

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Other Solution

Medical Records Coding

Authorization & Payer

EMR Medical Transcription