Collaborative Strategies for Effective Denial Prevention in Healthcare

  • Written by Yash Rajan
  • Monday 5th September 2022
Collaborative Strategies for Effective Denial Prevention in Healthcare VLMS Healthcare

It becomes stressful whenever we hear the name of denial. It gives us a tight scenario where we all have to think about its reasons and how to prevent it. So, before going further let’s understand first what denial management is? Denial Management is the process of thoroughly examining every denial, conducting an underlying cause analysis to determine why each claim was rejected, evaluating denial trends to identify a pattern by one or more insurance carriers, and redeveloping or re-engineering the procedure to minimize the likelihood of future claim denials. In essence, organizations want to reduce the frequency of denials by identifying both the underlying reason and the coded cause. Every incident where a payment is late or less than anticipated must be looked into. This is a crucial step in streamlining the revenue cycle.

Coders may all agree that they moan and roll their eyes when they get a denial. Instead of taking a proactive approach, they are now compelled to take a reactive approach that requires us to review Clinical documentation again, identify the problem, take into account facility- and payer-specific standards, collect supporting information, and resubmit in the hopes that the protocol will lead to the proper reimbursement. The goal of all revenue cycle specialists working in facilities, including CMOs, clinical documentation improvement services, and coders, is to discover a means to significantly decrease, if not completely eliminate, receiving the dreaded rejection.

So how should we achieve this?
One strategy would be to focus on those who have been diagnosed and are most likely to encounter difficulties. We all are familiar with them, including acute lung failure, infection, anemia, malnutrition, hyponatremia, encephalopathy, and a host of others.
Fortunately, some forward-thinking people and their businesses have thought of another potential answer.

Clinical Guideline Committees are being formed (CGC). This CGC is the same one that might eventually result in a national or perhaps international "guidebook" for clinical indicator recommendations that are accepted throughout the industry. Differences in payer and facility-specific, physician, and coder/clinical documentation improvement (CDI Services) criteria would be reduced by this collaborative approach.

Under Clinical Guideline Committee, following key people come-
Payers Facility representatives Billing Coordinators Physicians, Coders CDI professionals

The clinical guideline committees could go to condition experts for advice and feedback. They can also link software modifications that use AI (artificial intelligence) technology to increase the specificity of the answers provided by doctors when a problem is reported. The software firms call this merger real-time and interactive storytelling technology. The doctor who sees and interacts directly with his patient has the last word on the illnesses that are identified and treated, even though technology may be a tremendous tool for efficiency.

What is the problem then?
Getting all the collaborating entities to accept, adopt, and use the rulebook as an unified guideline is perhaps the biggest challenge. In the end, we must all cooperate to establish the standardization of clinical indicators that accurately reflect the conditions being assessed, identified, and treated. Let's all have huge dreams now to stop denials. Your constant companion in managing and resolving rejections is VLMS. We are aware of your requirements and will never leave you to face difficulties on your own. Our services simplify every challenge, and we provide comprehensive guidance on denial management. Because we offer top-notch services, all of our clients have faith in us. Claim rejection, denial management, and a number of other medical and healthcare services are just a few of the domains in which we have excelled.

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