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Home / News & IndustryManaged Care Insight and Analysis
Updated: December 22, 2009
Survey Respondents Cry Out For Denial Solutions: Standardization, Strict Punishments And Education

Claim denials are reported to be a major problem for over 90 percent of survey respondents, calling for national standardization among payors to improve payments.

According to the "Managed Care Leadership Survey on Managed Care Claims Payments," 20 percent said a national mandate of some sort should be established to help correct the high volume of claim denials from insurance companies.

"An outside source mandated by the Insurance Bureau that tracks insurance companies claims, denials, appeals, etc." is necessary, said the director of managed care for a hospital.

The director, along with 15 percent of respondents, said strict and enforced punishments for faulty denials would reduce the amount of denials.

"If insurance companies knew they were really going to be audited for ‘proper processes,’ more would be inclined to behave properly," the director said.

"There seems to be no significant penalty for unfounded, incorrect denials by payors," said the director of contracted care for an integrated health system. "Certainly providers are on the hook for up to 100 percent of contracted amounts when a mistake is made, not so for payors."

"If the price of a denial doubled when there was an inappropriate denial, much of this would stop," the director concluded.

A clinical professor at a medical university said whatever the punishment is, it "should be severe enough that nobody would want to risk perpetration."

An average of 13 percent of claims per provider are denied, the survey reported.

One regional director of a managed care program said there should be "tougher state and federal laws and a reported blemish on the health plan for many years – similar to credit reports on consumers."

Another 15 percent of survey respondents said the solution to claim denials is education for all involved.

"We need better education of the billing staff in the offices and continuous update and review of changes ... Providers need to invest in their associates who bills the services in order to maximize their claim acceptance on first pass. Industry standards, coding and billing guidelines changes and the providers must keep up-to-date," said the assistant vice president of an MCO.

Respondents said payors should be providing education services to ensure providers are equipped to submit claims correctly with proper coding and necessary information.

Another suggestion to aid the claims approval rate is to "eliminate the authorization process; most should either be covered or not, especially for DME (durable medical equipment) small dollar claims."

The survey was conducted by the Managed Care Information Center, an affiliate of Healthcare Reimbursement Monitor.

Address: Health Resources Publishing, Managed Care Information Center, 1913 Atlantic. Ave., Suite 200, Manasquan, NJ 08736; (732) 292-1100,

  This article was taken from:
Healthcare Reimbursement Monitor

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