How to Reduce Claims Denials

Apr 29, 2019

The reimbursement landscape is already a complicated one – and the highly-complex claims denials process only adds fuel to the fire.


A denied claim is one that has been determined by a payor to be in appropriate. Once a coding specialist amends the errors on a rejected claim, they can resubmit it for consideration.

The time-intensive process has a significant impact on the cash flow for any setting in the healthcare environment. They are also very costly to appeal.

Here’s some tips to avoid the headache that comes with claims denials:

Schedule Routine External Audits

Many organizations routinely perform internal audits as part of a compliance plan. Internal auditors have an insider’s view of the work flow of the organization. Unfortunately, they are auditing their coworkers, friends or employers.

The impact of not conducting regular audits and making necessary adjustments increases your chances of a claims denial.

Benefits of an external audit include:

  • External audits are completely impartial. The external auditors have no previous relationship with the coders or providers at the organization. Audits can be performed without fear of repercussions in the workplace.
  • External audits may provide validation to situations discovered during internal audits. In most instances, recommendations received from by multiple sources are better received.
  • External auditors are on your side. The goal is to look for potential opportunities to keep you compliant.
  • A fresh set of eyes may pick up on something that has previously gone unnoticed. External audits often reveal potential template or system irregularities, which can easily be corrected.
  • Trends can easily be identified, and the appropriate education and corrective action provided.
  • External auditors are focused solely on the audit. Internal auditors may have other job duties and responsibilities that could be a hindrance.

Complete and Thorough Documentation

Thorough, detailed documentation has always been essential to assigning accurate and complete coding to the inpatient course of treatment. The outline of quality measures used in a value-based payment methodology now makes it imperative for the outpatient/provider setting as well.

Better documentation provides for better care and care management, and, ultimately, better reimbursement.

Most importantly, better documentation will ensure you avoid a claims denial.

Continuing Education for Coding Staff, CDI & Providers

Continuous education for coders, documentation specialists and providers is of utmost importance – especially when it comes to avoiding claims denials.

Whether it’s providing real time feedback for new coders, or helping to refine the skill sets of more seasoned professionals, partnering with an experienced coding consulting company can provide the type of supportive mentorship that leads to long term success. A constructive, one on one approach that focuses on utilizing the proper references is key to developing an independent and effective coding professional – one that knows how to avoid claims denials.

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