The Coding Denial Defense: Industry Trends and Proactive Denial Strategies

Overthelastseveralyears,medicalclaimdenialrateshaveincreased significantly.In2016,claimsdenialrateswereabout9%andin2020,they increasedto11.3%nationally.Front-endrevenuecycleproblems,suchas registration,eligibility,authorizations,andunpaidservices,take responsibilityforhalfofthesedenials.Since2016,registrationandeligibility haveaccountedforthemajorityofdenials nearly27%.

Preventing Medical Claim Denials

Thegoodnewsisthat86%ofdenialsareavoidableorhavethepotentialtobe avoided.

About21%ofdeniedclaimsoccurduringthemid-cycleprocess.Thesedenials resultinthelossofmillionsofdollarsinrevenue.Frustratingandexpensive, thenumberofdeniedmedicalclaimscontinuestorise.Butthattrendcan changeifcodersunderstandtherootcauseofdenialsandtakeactionto improveclaims.

Understanding the Challenges of Claim Denials

Thereareseveralbarrierstoeffectiveclaimmanagementanddenial prevention:

• Attrition–complexclinicalcasesrequirerobusteducationandongoing training

• Thelackoffront-endandmid-cycledenialpreventionstrategies

• Non-automatedworkflowsforclinicalattachments

• Ongoingregulatorychanges

• Inconsistentsystemupdates

Managingcodingdenialsandclinicalappealsrequiresextensivecoding expertiseandclinicalknowledge,aswellasanalyticalskills.Unfortunately, manyhealthcareorganizationshavenotembracedthedenialprevention capabilitiesoftheirtechnologyplatforms,whiletheyarecontinuingtouse themonthefrontendofcoding.

Recognizing the Top Denial Trends

Themostcommonreasonsfordenialsin2021–2022includedtheuseof telehealthservicesasmodifiersthatwereimproperfortheprocedure,

improperuseofthecode’sCO-4andCO–199,andimproperuseoftherevenue code–CPT–Modifiercombination.Otherleadingreasonsfordenialsincluded: claimsbilledwithinappropriatediagnosisandnotmeetingthemedical necessity,primarydiagnosisinvalid,andnotfollowingICD-10guidelines.

Denial Improvement Impact

AGSHealthprovidesclientswithalistofcodingsuggestions,whichcan immediatelybeputinplacetoreducedenials.Additionally,ourteam consistentlydevelopscontentandhostswebinarstohelpcodingteamsstay currentaboutnewandupcomingchanges.Wealsosharecommoncoding challengestohelppreventdenials.

The AGS Approach

AGSHealthhasdeepexpertiseinRCM,includingcodingandbillingaspects, claimsmanagement,ARmanagement,patientverification,automation,and analytics.Ouranalysissatisfiesqualitystandardsandaccomplishesquality objectivesthroughoutthetransitiontoAGSsystems.Ourtrend-basedaudits aregroundedincustomerfeedbackandinternalanalysis.Wemaintainan impactof97–98%comparedtotheindustrybenchmarkof95%.

Formoreinformation,watchourrecentwebinar.

Source of content:

https://www.agshealth.com/blog/coding-denial-defense-industry-trends-and-proactive-denial-strategies/