Denial & Appeals Management

Our team thoroughly reviews the denial reasons and prepares strong appeals with supporting documentation to increase the chances of successful claim resolution. This helps maximize reimbursements for healthcare providers.

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MEDICAL BILLING & REVENUE CYCLE MANAGEMENT

Denial & Appeals Management

Despite our diligent efforts to put processes in place to prevent denials, some denials still happen. The time-consuming process of denial management, which includes tracking claim adjudication, identifying zero-paid and partially paid claims, researching reasons for denials, collecting necessary documentation, and writing and submitting appeals, need not be so laborious.

TriumpHealth’s denial management team combines people, process, and technology to drive denial prevention and identify the root causes of denials throughout the revenue cycle. We target high-impact denials by type and recommend process improvements to prevent denials that adversely impact cash flow.

Depending on the denial category, we task accounts to the appropriate staff member e.g. TriumpHealth coding, billing, and medical records staff, or practice front office, clinical, and administration staff when key performance indicators fall outside target ranges. We analyze denials per CPT, and per payer to drive root cause analysis. We auto-populate payer and CPT specific templates along with all necessary paperwork for payer appeals. Our staff also mails appeals and any associated attachments on your behalf, and then we follow up on them till adjudication.

TriumpHealth can significantly improve your denial management and collections.

Frequently Asked Questions

What is Denial and Appeals Management in healthcare billing, and why is it crucial for the financial health of medical practices?

Denial and Appeals Management involves identifying and resolving denied insurance claims and filing appeals where necessary, to ensure timely reimbursement for medical services rendered. It is crucial for the financial health of medical practices as denied claims can lead to revenue loss, increased administrative costs, and prolonged payment cycles, impacting cash flow and profitability.

How do you identify the root causes of claim denials, and what strategies are implemented to prevent future denials?

We identify root causes through thorough analysis of denial patterns, including coding errors, missing documentation, and payer-specific requirements. Strategies to prevent future denials include staff training on coding and billing best practices, implementing claim scrubbing software to catch errors before submission, and regular audits to monitor compliance with payer guidelines.

Can you explain the process of handling denied claims, and what steps are taken to initiate and manage the appeals process effectively?

The process involves reviewing denied claims, identifying reasons for denial, and determining if an appeal is warranted. If so, we initiate the appeals process by submitting additional documentation or rationale to support the claim. Effective management includes tracking appeal timelines, maintaining open communication with payers, and escalating appeals as needed to ensure timely resolution.

What role does accurate medical coding and documentation play in Denial and Appeals Management, and how do you ensure compliance with coding standards?

Accurate medical coding and documentation are critical as they directly impact claim acceptance and reimbursement. We ensure compliance by adhering to coding guidelines, staying updated on coding changes, and conducting regular audits to validate coding accuracy. Clear and comprehensive documentation supports appeal arguments and increases the likelihood of successful claim resolution.

How do you leverage technology to streamline Denial and Appeals Management processes, and ensure integration with other components of revenue cycle management?

We leverage technology by implementing denial management software, electronic claim submission tools, and analytics platforms to identify trends and patterns in denials. Integration with other revenue cycle management components enables seamless data exchange and workflow automation, improving efficiency and effectiveness in managing denials and appeals.

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Denial & Appeals Management FAQ

Our Process

Denial Analysis

Identify and categorize denied claims based on reasons such as coding errors, eligibility issues, or insufficient documentation.

Appeal Preparation

Gather necessary documentation and evidence to support the validity of the denied claims, including medical records, coding guidelines, and payer policies.

Appeal Submission

Submit well-prepared appeals within the designated timeframe, utilizing the appropriate channels and formats specified by payers, such as online portals or written appeals.

Follow-up and Resolution

Monitor the progress of appeals, track responses from payers, and provide additional information or clarification as needed. Work diligently to resolve denials in favor of reimbursement, escalating appeals to higher levels if necessary to achieve resolution.

Benefits of Working with TriumpHealth

Denials and Appeals Management

Reducing Denials Through Analytics

We analyze denial trends based on billing software set-up, patient demographics, specialty and payer rules, thus minimizing the denials.

Focus on Denial Prevention versus Denial Management

Our team uses an iterative process that identifies root causes, finding solutions to prevent issues from recurring.

Efficient Appeals Process

We effectively utilize appeal templates for specific payers and CPT codes, with relevant clinical documentation.

Key Performance Indicators

You can’t manage what you can’t measure, we constantly monitor KPI’s like denial rate and appealed claims percentage.

Top Rated by Healthcare Organizations

TriumpHealth has helped us with MU  and PQRS since 2013, and now MIPS. TriumpHealth has worked well for us because of their systems and compliance knowledge.
Having TriumpHealth support us in these efforts keeps my office staff focused on the patients. For any clinic stuck using Allscripts,  TriumpHealth can help.

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Denial & Appeals Management