Q&A: Root causes of denials

Q. How can we work to identify and correct causes of denials?

A. Start with the highest-volume or highest-dollar denials and perform a thorough investigation into the cases. If you have captured the detailed data recommended, this can be further refined down to the specific service, department, code, or physician contributing to the majority of your denials. During your review, your team should have the medical records, itemized billing statement, and coding information readily at hand.

A high number of the clinical/medical necessity denials will tie back to the physician’s documentation or orders. Be sure to note the specific issues missing or lacking in the documentation, along with the associated documentation requirements, before approaching the physician about the issue. In addition, this education is more effective when performed physician-to-physician; therefore, it is imperative to involve the physician advisor.

For more information, see The Denials Management Training Handbook.

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