Healthcare organizations should effectively manage claim denials and develop procedures for quickly resolving claims reimbursement issues. From improper ICD-10 coding to a missing signature on a patient’s charts, claims can easily be denied based on technical or clinical problems. Claims denials have also been on the rise as federal agencies and Payors work to combat healthcare fraud, waste, and abuse

Denial Management

Preventable / Avoidable

  • Timeliness
  • Expired Credentialing
  • Registration inaccuracies
  • Charge “Bundling”
  • Incorrect CPT/ICD CODES


  • Medical Necessity (some)
  • Additional information

Approach to Denial Management


  • What are your most common denials?
  • How do you track denials?
  • Upfront or backend errors?
  • Does the staff understand denials?


  • Registration inaccuracies
  • Eligibility /Referrals / Pre-auth
  • Charge entry errors
  • Coding inaccuracies
  • Credentialing
  • Timeliness
  • Root cause – Study the system
  • Physician training/Clinical
    Documentation Improvement

Execute – Trends & Strategies

  • Weekly, monthly, yearly
  • By category / provider
  • By payer
  • By Dirham amount
  • By User
  • Graph out trends/results for
    everyone – visual impact
  • Contracts loaded and updated

Recovery management

During the last 2 years we seem to have more audits and reviews of our charges and reimbursements then ever before, as the government and the payor  reviewers examine our billing.  These Audits can complicate life for a physician. Ensure that your services are properly documented. While “if it isn’t written it wasn’t done” is not the law, payors believe that it is, and they will attempt to recover any insufficiently documented service. Make certain that you are complying with the DoH and Payor policies like those governing services “incident to” a physician’s services and the supervision of diagnostic tests. The penalties can be quite significant for those who do not comply and function within the current regulations. We help in preparing you for these audits and also help in Recovering monies which have been taken back due these recovery audits.

  • Evaluate and ensure that all claims denied or underpaid inappropriately by payers are identified, appealed and reversed.
  • Work closely with appropriate departments/areas , e.g. HIM/coding and medical teams, to review and obtain medical documentation required to facilitate denial appeals process.
  • Proactively work with multidisciplinary teams within, to develop procedures to reduce denials received through reporting and education of denial trends
  • Works with management on payer contract interpretation, updating and distribution of correspondence to hospital staff as required.
  • Compare, analyze and report on data related to underpayments, denials, revenue opportunities and revenue leakage. Categorize denials based on root cause findings and distribute reports and metrics to applicable management and teams