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Denial management

Catherine Boerner (cboerner@boernerconsultingllc.com) is President of Boerner Consulting, LLC in New Berlin, WI.

When conducting an effectiveness review, I often ask how the compliance department is involved with denials management. Is a member of the compliance department staff on a denials steering committee or other committee where denials are compared over time and where root causes are discussed? Are technical denials, such as duplicate claims, separated from clinical denials, such as medical necessity? Who owns each category? Compliance officers may have a role in connecting clinical staff with these financial results to gain a better understanding of how to prevent these denials. This process includes an analysis of denial reason codes, billing department codes, avoidable write-offs after reviewing denials, etc. It helps when this analysis groups together all denial codes that are related to coordination of benefits, or groups together all write-off reasons that are specific to authorizations. Compliance officers often see opportunities to facilitate and/or provide specialized compliance training to educate on the documentation and coding requirements that result in some of the denial trends.

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