Claim denials in medical practice are inevitable. You can take as many precautions as possible and add as many steps to the process to ensure claims are submitted cleanly, but denials are unavoidable. The aim, then, should be to keep the percentage of claims that are denied low, though this takes time and money to achieve.

There are many reasons insurance providers can deny payment; “medical necessity” is one of these, with certain studies showing that this is the 2^nd most common cause of denials experienced by patients. Individual payers will also have different policies and guidelines surrounding when a procedure or treatment is deemed not medically necessary. In a world where insurance decides medical necessity, how are providers to continue treating patients to the best of their abilities, while still being paid?

Keep reading for 5 tips on avoiding medical necessity denials.

Appoint a Payer Policy Expert

A member of the practice, or even a third-party biller or coder, should be appointed to stay on top of payer policy regarding medical necessity. This expert will help the practice navigate the constantly changing rules and regulations of the many payers they are contracted with.

Monitor Trends in Denials

Providers should closely monitor and trend their denials; this helps in identifying the most frequent forms of denials and the ones that cost the most money. This can also help quickly identify denials that occurred due to an error on the payer’s side, which can happen in the case of medical necessity. The denial might have been caused by an outdated policy or one which is not applicable in the particular case.

Learn More: Top 10 Reasons for Claim Denials

Appeal

Starting with the most common and costly denials, providers should appeal in every case where a claim is denied. Creating a denial appeal template can help save time in doing so.

Edits in the Practice Management System

The ability for coders to review and edit claims in the practice management system before they are submitted can help identify potentially problematic claims before they are submitted. These claims can then be scrubbed, ensuring the right codes are attached to each procedure or medication.

Get Patients Involved

Denials hurt not only patients that are unable to pay, they also hurt providers by significantly reducing their chances of getting paid in full. The best route for both is to work together through the appeals process, which providers can do by having patients sign a form authorizing them to represent the patient in a denial appeal.