Denials – Reshape your A/R in 3 Simple Areas

Take Action

1. Create a report off your most recent 835 remits for each account number. Review all adjustments for Benefits Exhausted, Missing Referral, and Missing Medicare ABN. Put these reports into the scheduler to be distributed to the responsible individual(s) on a daily basis.
2. For claims that are denied for Benefits Exhausted, depending on the payer, the exhausted balances should be written off according to your write-off policies and procedures, including charity or uncompensated care. In other cases, the amount is billed to the secondary payers or the guarantor/patient.
3. For Missing Referral, create a report for all qualifying denied claims by admitting physician. Have the appropriate leader talk to the physician practice management team and/or talk to the service department to change their practice and reschedule all patients for whom no referral exists. We also recommend running a report for Missing Referral by Location and by Total Denied Dollars. Use your findings to enforce the protocol that does not allow scheduling a patient without a referral.
4. For Missing Medicare ABN, segment your data by ER vs. non ER. Research if the ABN was necessary – if yes and it was not secured, and it was not an ER patient type, the account’s propensity for any payment drops dramatically and should most likely written off. If the ABN was not necessary, and the procedure was medically necessary, then re-submit according to your medical necessity appeal procedures. Or if a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

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