In the intricate realm of healthcare management, one challenge looms large for medical practices—denials. The Medical Group Management Association (MGMA) conducted a recent poll that unveiled an alarming trend: 69% of healthcare leaders reported an increase in denials in 2022. The reasons behind these denials are varied, including non-reimbursement for COVID-19-related supplies, critical care claims, and imaging CTs etc. As denials make their presence felt, medical practices are tasked with a critical mission—to decipher and address the root causes behind these rejections. 

Fighting the Denials Battle of DME Billing and Coding Operation: 

Today denials in DME/HME billing are not just a concern; they're a burgeoning issue in the healthcare landscape. According to Change Healthcare's 2020 Revenue Cycle Denials Index, the denial rate has surged by 23% since 2016, with an additional 11% spike since the onset of the COVID-19 pandemic. Despite the pandemic's influence, the core causes and sources of denials have persisted over the years. In fact, people managing medical billing affair underscores the significance of addressing front-end issues. Registration and eligibility, accounting for nearly 27% of denials, persist as a top concern. Another 11.6% of denials stem from authorization/pre-certification issues, with 10.6% attributed to services not covered. Astonishingly, half of all denials result from front-end challenges.

It is no secret that denials, if unaddressed, come at a cost—the average price to rework a claim is $25.20. However, the silver lining lies in the fact that a significant portion of denials can be avoided. In fact, a staggering 86% of denials are potentially preventable. This revelation underscores the importance of proactive measures and strategies. 

Turning the Tide with Proactive Strategies 

  1. Analyze & Identify: Understand where errors and slowdowns are occurring. This analysis helps pinpoint denial root causes and their impact on the revenue cycle. 
  2. Focus on Six Key Areas: Direct efforts toward registration/eligibility, authorization/pre-certification, medical necessity, medical coding accuracy, valid claim data, and services not covered. 
  3. Communication is Key: Train front office staff to inquire about additional coverage and confirm eligibility before submitting claims. Maintain a vigilant approach to patient insurance details. 
  4. Stay Ahead of Authorization: Compare authorized services against ordered and performed ones before the service. Communicate with physicians and payers to ensure accurate authorizations. 
  5. Medical Necessity Validation: Engage in peer-to-peer meetings and ensure complete clinical documentation submission for continued stays. Document the severity of a patient's condition comprehensively. 
  6. Coding Precision: Focus on accurate discharge status coding, up-to-date charge master, and meticulous documentation of patient health status at admission. 
  7. Comprehensive Claim Scrubbing: Verify there are no missing payers IDs, procedure codes, or invalid diagnosis codes. Ensure the claim scrubber is equipped for high quality edits. 
  8. Address Uncovered Services: Collect payment upfront for services not covered, particularly for Medicare patients. Secure signed Advance Beneficiary Notice (ABN) forms to avoid post-procedure denials. 

As denials loom larger in the healthcare landscape, one convenient solution to manage DME denial is outsourcing your DME billing. A proactive stance, fortified by meticulous front-end processes, technology optimization, and internal resilience, not only help stem the tide of denials but further ensure better ROI in no time. By understanding the sources, focusing on prevention, and executing strategic interventions, RCM solution like Sunknowledge can not only retain revenue but also fortify their financial health.