Denial Analysis: Improving Healthcare Reimbursement
Particularly in the past few years, insurers have begun denying a larger and larger percentage of legitimate health care claims. In view of the steadily increasing costs for both managed care and indemnity coverage, this is widely viewed as a tactic to increase insurance company profits at the expense of beneficiaries. Since there is no way to prevent unfounded denials, the only recourse for providers is to appeal consistently, tenaciously, and effectively. Experience has shown that the majority of denials are overturned when a well-constructed appeal is mounted.
This increase in denials has also spawned a new industry: helping practitioners appeal denied claims. Appeal Solutions [ www.appealsolutions.com ] is one example of a company focusing exclusively on health care appeals. Although their primary emphasis is on hospital claims and medical denials, their site often has information that can be useful for P&O practices too.
They recently published an article recommending formal tracking of denials as a method to increase successful appeals. Based on the principle that "what gets studied gets improved", the gist of the recommendation is to set up a simple Excel database and record all denied claims, the steps required to appeal, and the ultimate result. Unlike simply fighting each denial in isolation, this approach makes it easy to spot trends in denials, either from specific insurers or more broadly across insurers. For example, if an increase in denials based on the limitation of coverage to "standard care" becomes apparent, you can include additional documentation in the initial filing emphasizing that the P&O care is not "deluxe" but is the minimum medically necessary to effectively treat the identified biomechanical deficit.
When denials were an occasional headache in O&P, it was practical and generally effective to deal with each incident individually. But, now that unfounded denials are more common and have almost become "standard operating procedure" for lower quality insurers, it makes more sense to challenge this growing threat to the facility in a more formal manner. To read more about this strategy, go to www.appeallettersonline.com .
