Medical necessity denials remain a significant challenge for healthcare organizations, often resulting in delayed reimbursement, increased administrative burden, and potential revenue loss. Unlike other categories, these denials can be particularly difficult to resolve as they frequently involve complex payer policies, coding nuances, and, at times, extensive documentation requirements.

​Many healthcare professionals rely solely on denied claim data to monitor denials. While this approach is logical, since denial data highlights the reasons for non-payment, services being denied, and responsible payers, it shows only part of the picture. Transaction and accounts receivable data also provide valuable denial insight. 

​​Identifying denial trends is essential for addressing internal process gaps, but it is equally important to understand the broader financial impact these denials pose.

There is one denial reason code that consistently ranks among the top denied categories in every organization, yet it is rarely discussed. One payer response that no one wants to see is CO-16. This code requires additional effort on the backend to ensure the claim is fully paid. Sometimes, it can feel like a guessing game when trying to interpret what the payer truly requires with this reason code. To prevent “other documentation” denials, organizations must be proactive in identifying the root cause and implementing workflows for future prevention. 

​By: ​Ashley Hunter, MBA, CHFP, CRCR, Stevie Zarle, and Briauna Driggers

​When examining the top five denial categories at any organization, authorizations are almost always among them. Obtaining authorization approvals has become significantly more challenging in recent years with frequent changes in payer policies and authorization initiation processes. This poses a significant challenge for healthcare organizations as these denials are often “hard” denials, leading to avoidable revenue loss. The key term here is “avoidable,” as these types of denials can be entirely prevented with the right processes in place. 

​As flu and COVID-19 vaccines become essential during peak seasons, ensuring accurate coding and detailed documentation is crucial. Vaccination documentation directly impacts reimbursement, compliance, and patient safety. Yet coding errors and missing details are common issues that healthcare providers face. This article breaks down the critical elements of vaccination documentation and offers practical tips for improving accuracy, helping practices navigate the intricacies of vaccination coding.

By: Briauna Driggers and Juan Arredondo

Medicine is an essential service. Yet, healthcare providers still need to make enough profit to cover their overhead costs if they want to keep their doors open. That is why it is essential for your business and community that claims are processed accurately and you get reimbursed for your services.
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Unfortunately, claim denials are on the rise, up over 20% since 2016. The COVID-19 pandemic only exacerbated the situation. There was a sharp rise in patients seeking medical care and an 11% increase in claim denials nationally. While almost 85% of these denials are preventable, about a quarter of them cannot be recovered. 

By: Briauna Driggers

The Medical Revenue Cycle is integral to any hospital or free-standing practice. We've discussed before how important accurate medical coding is and the impact it has on the Revenue Cycle, but what else impacts the success of revenue cycle management (RCM)? Let's talk about Key Performance Indicators (KPIs) and how they contribute to an efficient and effective revenue cycle.

By: Briauna Driggers

The mark of success for a revenue cycle is receiving full and timely reimbursement. But the question is, “how do you make sure you’re fully reimbursed and on time?” The answer may seem complex, but it comes down to accurate medical coding. Medical billing and coding are two of the most crucial factors of the revenue cycle, yet the importance of coding accurately is often not monitored, assessed, or facilitated as much as it should be. Accurate medical coding means clean claims, prompt reimbursements, and an overall positive bottom line. Any coding errors throughout the medical billing process can lead to lost revenue.