How to Recover After a Denial Strategies for Resubmission Success

Introduction

Few things are as frustrating for DME providers as receiving a denial from a payer. Whether it’s due to credentialing errors, missing documentation, or complex coding requirements, denials can disrupt your revenue cycle and delay patient care. However, a denial doesn’t have to mean lost revenue.
In this blog, we’ll explore effective strategies to recover from denials, streamline resubmissions, and prevent future rejections, ensuring your claims process stays on track.

Common Reasons for Credentialing-Related Denials

1. Uncredentialed Provider Submissions
   • Cause: Claims submitted for services provided by a clinician not yet credentialed with the payer.
   • Solution:
     • Verify credentialing status before submitting claims.
     • Use credentialing software integrated with your billing system to flag uncredentialed providers.
2. Missing or Incomplete Documentation
   • Cause: Lack of required documentation, such as clinical notes or proof of medical necessity.
   • Solution:
     • Maintain a checklist for each payer’s documentation requirements.
     • Train staff to double-check claims before submission.
3. Errors in Claim Coding
   • Cause: Incorrect or outdated coding for DME services and equipment.
   • Solution:
     • Use up-to-date coding resources like HCPCS and ICD-10 manuals.
     • Implement regular coding audits to catch errors before submission.
4. Missed Filing Deadlines
   • Cause: Late submissions due to inefficient workflows or lack of follow-up.
   • Solution:
     • Automate reminders for claims submission deadlines.
     • Assign dedicated team members to track high-priority claims.

Strategies for Resubmission Success

1. Identify the Root Cause of the Denial
   • Why It Works:
     Understanding the reason for denial ensures you correct the issue before resubmission.
   • How to Do It:
     • Review the Explanation of Benefits (EOB) or denial notice for details.
     • Cross-check with payer guidelines to identify discrepancies.
2. Gather Supporting Documentation
   • Why It Works:
     Providing complete, accurate documentation reduces the likelihood of another rejection.
   • How to Do It:
     Compile all necessary records, including proof of medical necessity, prior authorizations, and provider credentials.
3. Correct and Resubmit Claims Promptly
   • Why It Works:
     Timely resubmissions keep your revenue cycle moving and avoid payer filing deadlines.
   • How to Do It:
     • Use claims management software to track resubmission timelines.
     • Double-check claims for accuracy before resending.
4. Escalate When Necessary
   • Why It Works:
     For unresolved denials, escalation ensures your claim gets the attention it deserves.
   • How to Do It:
     • Contact payer representatives directly to discuss the claim.
     • Provide a detailed summary of the issue and supporting evidence for review.
5. Monitor Trends to Prevent Future Denials
   • Why It Works:
     Identifying patterns helps you address systemic issues and improve processes.
   • How to Do It:
     • Analyze denial reports to pinpoint recurring problems.
     • Implement targeted training for staff to address gaps.

Proactive Measures to Reduce Denials

• Streamline Credentialing:
  • Ensure all providers are credentialed with payers before billing.
  • Use credentialing tools to track application statuses and deadlines.
• Audit Claims Regularly:
  Conduct routine checks for coding accuracy and documentation completeness.
• Educate Your Team:
  Provide ongoing training on payer-specific guidelines and regulatory changes.
• Leverage Technology:
  Use claims management and credentialing automation software to minimize errors.

How WWS Can Help

Denials don’t have to derail your revenue cycle. At WWS, we offer comprehensive support to help you recover and prevent future issues:

• Denial Management Expertise: We analyze EOBs, identify root causes, and implement corrective actions for successful resubmissions.
• Claims Tracking Tools: Our technology ensures timely resubmissions and minimizes delays.
• Credentialing Integration: We align your credentialing processes with claims workflows to reduce credentialing-related denials.

Schedule a consultation with WWS today to streamline your denial recovery process:
Schedule a Meeting with WWS.

Conclusion

Denials are an inevitable part of the healthcare landscape, but they don’t have to mean lost revenue. By understanding the reasons behind rejections, leveraging effective resubmission strategies, and addressing systemic issues, you can turn denied claims into opportunities for process improvement and financial recovery.
Partner with WWS to optimize your claims and credentialing processes—schedule your consultation today!