Denial Management is a critical component of Revenue Cycle Management (RCM) in healthcare, focusing on preventing, identifying, analyzing, and resolving claims that have been denied by insurance payers. Effective denial management ensures that healthcare providers maximize reimbursements and reduce the number of claims that are denied or delayed.

What is a Denied Claim ?

A denied claim is a claim that an insurance company refuses to pay, typically because of errors or discrepancies. This differs from a rejected claim, which may not have even been processed due to basic errors, and can be resubmitted after corrections. A denied claim, on the other hand, has been processed by the payer but payment was denied.

Denial management involves understanding the reasons for denials, preventing future denials, appealing incorrect denials, and resubmitting claims where appropriate.

Common Reasons for Denied Claims :

Eligibility Issues :

The patient may not be covered by the insurance on the date of service, or the services provided might not be covered under the patient's plan.

Missing or Incorrect Information :

Claims may be denied due to incorrect or missing patient information, coding errors, or incorrect provider information.

Common issues include

  • Inaccurate patient demographics (name, date of birth, insurance ID)
  • Incorrect National Provider Identifier (NPI) numbers
  • Incorrect insurance plan details
Timely Filing :

Most insurance companies have strict deadlines for claim submission. A claim submitted after the deadline can be denied due to untimely filing.