Denial Management

Denial rates vary widely depending on physician specialty. Denials for some specialties, such as obstetrics and gynecology, can be as high as 20 percent. Denials for primary care practices can be 10 percent or below. As a rule of thumb, a denial rate of 15 percent affects practice profitability.

Obtaining an accurate reflection of denials for a multispecialty practice can be challenging. “The denial rate for a multispecialty group practice may be 5 percent, but that overall rate may include a 20 percent denial rate for obstetrics and a rate of 1 percent for family practice. You need to look at denial rates by type of specialty. We segregate denial rates for primary care [family practice and internal medicine] from those for specialties that have potentially higher denial rates.

When the denial rate is high, it should be looked at immediately. We address two areas of denials: why they are occurring and preventing them in the first place. At Physibill, we are dedicated to analyzing these issues and implementing strategies to reduce denial rates and improve practice profitability.

At Physibill, denial management goes beyond simply resubmitting claims. Our team of experts thoroughly analyzes the reasons for denials, identifies the most common factors, and systematically works to eliminate weak links. Our comprehensive collections and denial management support have significantly reduced claims rejection rates, helping practices achieve better financial outcomes.

Information verification before the bill goes out the door:

The most common reasons for denials include incorrect information such as inaccurate ID numbers, misplaced CPT codes or modifiers, misspelled names, or discrepancies between names and those on the patient’s insurance card.

At Physibill, we ensure that all these details are thoroughly verified before claims are submitted to prevent such issues.

Focus on reasons of denials:

At Physibill, we understand the complex regulations surrounding billing to ensure it is done correctly from the start. The proliferation of managed care plans, stricter Medicare and Medicaid regulations, and the frequent need for payment authorizations can lead to higher denial rates if not proactively managed.

By identifying denials linked to billing processes and thoroughly investigating their causes, we help clinics error-proof their procedures, significantly reducing the likelihood of future denials.

Internal Process:

At Physibill, we take proactive steps to address denials by resubmitting claims well before you receive the paper denial through the mail. By contacting the insurance company directly to determine the denial reason, we can correct the issue and resubmit the claim without delay.

Resubmitting claims a few days earlier than waiting for the denial notice can significantly shorten your payment turnaround time. Our approach ensures that you get a head start on resolving denials and keeps the healthcare claims process moving efficiently.

We don't assume the insurance company is right:

we monitor unclaimed revenue reports and appeal denials when appropriate. We understand that insurance companies may issue denials in error or due to outdated systems. If we determine that a denial is incorrect based on your agreement, we will appeal the claim.

Additionally, our team provides updates to the practice on changes in health insurance billing guidelines—such as revising billed amounts—to ensure you receive the maximum value from contracted payments.

We don't assume the insurance company is right:

Building rapport with insurance representatives during AR follow-up calls is crucial. It helps us find solutions for cases where claims have been denied consistently for various reasons, including global issues. In some instances, representatives may become uncooperative or withhold important information needed to proceed with claims, so it’s essential to handle these situations carefully.

Our AR representatives at Physibill are skilled in interpersonal and communication techniques, ensuring that insurance representatives feel comfortable and making the call as smooth as possible.

When do we call patients?

At Physibill, we address several critical issues to ensure smooth claims processing:

Missing Insurance Coverage Information: We address situations where no insurance coverage information is found in the demographics section of the patient’s account.
Eligibility Denials: We handle claims denied by the insurance company due to patient ineligibility at the time of service, which may occur if the service date is before the effective date or after the termination date of the patient’s insurance coverage.
Incorrect Personal Information: We correct any inaccuracies found in the patient’s personal information, such as name, social security number, date of birth, address, etc., in the patient’s account.

Shopping cart

Denial Management