|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
"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
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
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, www.healthresourcesonline.com.