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Pathway to Role of Coders in Denial Management: The Twist and Turns

The healthcare industry is experiencing many changes, from advances in medical technology to increase in expenditures that lead to new challenges. The industry has been chiefly concerned with the need to ensure that patients received high-quality care and getting paid for that care.

For years, financial challenges have affected the world’s private and public healthcare systems to varying degrees. These challenges are further expected to persist with the recent outbreak of the COVID-19. While the pandemic currently has a high impact on the insurance coverage, denied claims continue to be one of the pervasive and persistent obstacles.

Claim Denials Represent a Significant Financial Drain and More

The revenue cycle of large hospitals and health systems contain many touchpoints, leaving an ample room for claim rejections and claim denials. Some of these denials happen for a number of reasons such as optometry medical billing mistakes, operational inefficiency, as well as staff errors during patient scheduling, registration, and coding. Most commonly, denied claims result from medical coding mistakes due to lack of skilled staff or inadequate clinical documentation.

Denied claims and the subsequent amount of time and money spent on denial appeal leave the hospitals on the hook. In some cases, the hospitals or health care providers charge the patients for unpaid services, who do not leave positive reviews for the systems. Such issues not only impact the satisfaction score of the patient but also deteriorate the reputation of the hospital.

Understanding the Importance of Denial Management

The process of denial management helps healthcare businesses not only to investigate the unpaid claim but only to uncover insurance trends and appeal the denial in an appropriate manner. Additionally, the rejection code and the actual reason for rejection are not related in most cases. This makes it important to seek the root causes of coding denials.

Following the evaluation of the cause, denial management develops a specific process to appeal claims that are initially denied. Accurate and consistent coding for denial management remains important to these procedures.

Claim denials associated with no or insufficient documentation and medical necessity are complicated. The approach must be to focus on improving the process such as clinical validation performed by a clinician with approved coding credentials. On the other hand, denials related to incorrect coding can be reviewed through DRG validation which ensures accurate code assignment.

Coders – A Key to Optimize Denied Claims and Revenue Cycle

Today, coders play an important role in ensuring the smooth revenue and cash flow of healthcare business owners. While coders cannot clinically validate a medical condition, they can ensure medical necessity and identify documentation to support the payment for the services.

Skilled coders with a greater understanding of the proper use of Advance Beneficiary Notices (ABNs) in medical billing significantly contribute to denial management. Moreover, it helps identify process deficiencies and in denial avoidance.

The significant role of coders also involves three important steps - 1. reviewing the medical documentation available in the revenue cycle system, 2. analyzing historical coding denial trends, and 3. initiating proactive action to prevent the same in the future. Furthermore, certified coders understand the significance of Current Procedural Terminology (CPT) codes and procedures for medical coding. It can help in efficiently reducing common denials in optometry medical billing.

CSEYE, with our medical billing experts and certified coders, offers complete optometry billing support, which ultimately focuses on processes that improve claim management and avoid denials. Outsource medical billing for your optometry practice and reduce denials with CSEYE. Connect with us to witness drastic improvement in your denial management and offer the best customer service to your patients.

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