Denial Management in Healthcare

Denial management in healthcare is a process by which healthcare organizations and providers identify the reasons for claim denials and take steps to prevent them. Reimbursements are providers’ biggest source of revenue; denials or rejections of claims can hurt revenue cycles. Solutions for denial management in medical billing help to know why payers have denied certain claims, enabling providers to address that problem and increase their incomes. Denial management solutions have become extremely important since the loss of reimbursements costs the healthcare industry billions every year. 

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Explore Denial Appeal Management

Denial management in healthcare is one of the most crucial elements that ensure steady cash flow and powerful revenue cycle management. Denial management services include identifying the key problems that cause claim denials, classify them based on cause & source, and develop an effective denial management software strategy.

We provide tailored denial management solutions that help to enhance their clean-claims rate, manage denied claims effectively and have proficient assistance in handling the appeals. Our healthcare denial management can help providers to identify and exact causes of denials to improve your clean-claims rate. It can streamline workflows for faster appeals and improved cash flow while lowering the cost of managing denied claims and the administrative burden. Resolving underpayments while reducing regulatory risks to keep the financial performance optimum is the primary goal of OSP’ tailored healthcare denial management systems.

A well-defined advanced payer rule engine helps to track payer-specific rules for claim payments, identify their denial activity and recognize new rules. Defining claims qualification for each payer within the system can be made possible with a sophisticated payer rule engine. It can anonymously track these rules for each user base and automatically distribute current rules over the entire network.

OSP can build a custom denial management in medical coding that can assess your 835-remittance data to reveal the major reasons causing the claim denials. Our tailored healthcare denial management systems can analyze, track, and create intuitive reports on denial data in order to discover unpublished payer rules. We can customize the denial management software to recommend the relevant fixes for each denied claim. A rule engine can help implement the right billing processes to reduce the denials rate and increase revenue flow.

The potentially high cost of appeals emphasizes the value of implementing an effective denial management process. An organization’s clean claim rate is one of the highest priorities. Clean claim rate (CCR) is defined as the ratio of passed claims that pass edits cleanly. The cleans claims do not require any correction or manual work prior sending it to the payers.

Our denial management in medical billing helps to simplify the transactional complexities between providers and payers by creating a seamless process of error-free claim submission. Though our custom denial management services, we focus on increasing the CCR through the revenue cycle to the point of claim creation, data collection has been correct and efficient. The solution can be tailored to provide timely claim alerts to notify them being flagged by the rule engine.

In-depth analysis of root cause of the claim denials is highly crucial for denial management in US healthcare. As per the HIMSS analytics survey of 2016, more than 50% of hospitals do not leverage denial management analytics, eventually failing to reduce the denial ratio. The analysis helps to understand the standard triggers which cause claims denials instantly and the current faulty system can be optimized for better results.

We help the provider to understand the denial data and make it meaningful for the users with real-time analytics and easy-to-understand dashboards. Denial management medical billing can be made effective by visualizing the highly common denial trends. Healthcare denial management can be focused on these trends to create a smart action plan with alert parameters. The dashboard provides valuable performance metrics like initial denial rate, the rate of appeals, and win/loss ratio to streamline healthcare denial management in RCM.

Automated claims management system or medical clearinghouse solutions are the most important part of denial management solutions. Before submitting the electronic claims to the payers, the in-house medical clearinghouse solution scrubs the claims for any missing data to validate the claims against payer-specific rules. Providing all users with a single, on-demand solution for managing every aspect of claims denial, from receipt to resubmission is the highest need of the hour.

OSP’ advanced claims management solutions thoroughly scrub the claims and flag those require review. This help to resolve the issues and errors before submitting the claims. A detailed claims processing report offers a complete list of errors and causes of rejections which are needed to be resolved for claim submission. Healthcare denial management systems can be customized for payer-specific rules to optimize the efforts of claims processing.

As per the Advisory Board’s survey, the provider claims denial appeal is not a successful venture. The success rate for such appeals has dropped from 56% to 45% for private health plans. Denials for the patient in the emergency department are easy to appeal but managing the appeals successfully for a person being treated for a longer period of time is a cumbersome task.

OSP can replace the manual process of appeals and grievance management (A&G) by streamlining the complete process through automated denial management in US healthcare. A smart interface can help you to manage a seamless workflow for effective denial management in medical coding.  Automating the ongoing manual appeals management process can help providers to reduce stress, time and money needed to invest to get reimbursed for their authentic medical claims.


It should come as no surprise that denial management software has become a must-have for healthcare organizations of all sizes. The reasons for denials can vary from patient to patient, but it costs providers all the same. The healthcare denial management solution that OSP can build is an investment that pays off in the long run by preventing delays or losses in reimbursements. In other words, this type of software provides sizeable returns on investment.

OSP can develop a suite of claims denial management to cater to the needs of all types of healthcare organizations. These include dental clinics, physiotherapy centers, psychiatric care institutions, outpatient care centers, in addition to large hospitals. We customize the features of healthcare denial management software to suit the needs of the respective organizations. Our solutions will enable all providers to improve their revenue cycles and better serve their patients.

Managing the denials of reimbursement claims involves assessing the claims themselves and addressing their problems. In other words, the claims need to be scrubbed to fix any problems that would cause payers to deny or reject them. The denials management software we can offer automates many processes in claims scrubbing and other denial management activities. As a result, providers can experience greater productivity at lower overhead.

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