Denial Management

Denial Defender^® Optimized Claims

The best type of Denial Management is preventing denials by optimizing claims prior to submission. Should you get a denial, reporting and trending is critical to developing internal practice processes to avoid future denials.

After your charges are entered, Denial Defender^® from HealthFusion^® will assist you in optimizing the claim to avoid rejections and denials. The claim is compared against a sophisticated database of standards that contain millions of edits designed to avoid health plan rejection and denial. Denial Defender verifies modifier usage, checks for CCI bundling edits (CMS' National Correct Coding Initiative), determines code validity, displays Relative Value Units (RVU), validates pass-through items, and verifies medical necessity. In addition, Denial Defender will alert you real-time if any charges entered into claims are inconsistent with the current Medicare coverage guidelines.

With Denial Defender, Know that Your Claims Are Ready:

• The diagnosis code is valid for the date of service billed.
• When diagnosis code is limited as a secondary diagnosis only.
• The diagnosis code is appropriate for the gender and age.
• The procedure code is valid for the date of service billed.
• The procedure code is appropriate for the gender and age.
• The modifier is valid for the date of service billed.
• If an Evaluation and Management (E/M) and a procedure are reported, is an E/M modifier present?
• The modifier is consistent with the Current Procedure Terminology (CPT)/modifier crosswalk.
• If E/M, does the date of service fall within the global period of a previous procedure?
• If there are multiple codes, are codes sequenced appropriately based on RVU?
• Is there a Local Coverage Determination (LCD) or a National Coverage Determination (NCD) issue related to the procedure/diagnosis codes used?

By optimizing your charges as they are saved to the HealthFusion system, your practice will avoid denials and enhance reimbursement. Do not wait until the claim is rejected or denied – Get it right the first time and optimize your claim with HealthFusion's Denial Defender.

Denial Defender Reporting

Denial Defender reports can be run using data mined from Electronic EOB^® (Explanation of Benefits) / ERA (Electronic Remittance Advice) transactions, manually posted EOBs, and unsolicited claim status data like U277 notifications or text-readable reports. In addition, the system automatically reports monthly on the following metrics:

• First Pass Clearinghouse – Percentage of claims that are accepted upon initial submission
• Total Rejects – The total number of rejections and their dollar value
• Top Reject Categories – The most common reject categories
• Total Denials – Total number of denials and their dollar value
• Top 10 Denial Categories – The 10 most common denial categories
• Top 10 Denial Categories Excluding Contractual Adjustment (CA) – The 10 most common denial categories excluding CA
• Denial Group Comparison Report – A comparison of denials based on the HIPAA group code determination
• Denials Related to Front Office – The total number of denials and the percent related to front office functions
• Denials Related to Coding – The total number of denials and the percent related to improper diagnosis and procedure codes
• Denials Related to Timely Filing – The total number of denials and the percent related to timely filing
• Reworked Claims – Payer-rejected claims that were resubmitted
• Transaction Summary – Overview of transactions and counts
• Adjustments Summary – Summary table of all claim adjustments for all payers
• Patient Responsibility by Payer – Summary table of percentage patient responsibility.

Standard Denial Defender reports provide users with "single-click" access to powerful practice key performance indicators and options, including on-screen preview with sortable columns, color charts, export to Microsoft^® Office Excel, and save as a PDF.

HealthFusion works hard to prevent denials and rejects by assisting your practice in optimizing your claims prior to submission. However, if your practice does receive a denial or rejection, our comprehensive reporting suite will assist your team in analyzing and understanding rejections and denials. Your team will be able to track and trend your performance, compare your current month's metrics with the prior months', and easily track the bottom line impact of process changes made by your billing and collecting team.