Denial management (DM) is an integral aspect in any health organisation for healthy cash flow, and a successful RCM. ABA providers need to determine the reason for denials, lessen the risk of future denials,and strategize to get paid faster.
Any DM involves the following steps collecting, tracking, reporting, forecasting, measuring claims denied for payments by insurance companies or carriers as it helps forecasting the losses in revenue.
In recent studies conducted by the Medical Group Management Association (MGMA), have estimated it costs $25-$30 to manage an average denial. A report in 2020 What they found is that at nearly 27%, registration and eligibility remains the top reason for denials and continues to shine a spotlight on the need for innovative solutions that drive greater intelligence and automation into the front end of the revenue cycle, says Nick Raup, associate vice president, product management, revenue cycle solutions, Change Healthcare.
While the Change Healthcare survey discovered that the three of the top four causes occur at the front end of the revenue cycle, with authorization/pre-certification (11.6%) and service not covered (10.6%) also figuring prominently. Overall, most denials are caused by front-end issues.
ABA practices are aimed to serve individuals with ASD (Autism Spectrum Disorder) . Hence billing for ABA is unique, where the bills need to be submitted weekly across multiple service locations such as clinics, schools, homes and communities. Any Denial Management needs a high level of attention, while processing it and every ABA provider needs to understand that its DM is directly integrated into RCM. This will provide effective support for ABA denials management and help oversee the process that does not have any cashflow fallouts in an ever-changing environment.
Types of Denials in ABA
Denials Spectrum can be classified into two main categories:-
The types that are irreversible and often result in lost or written-off revenue are known as Hard denials
The types that are temporary and can be reversed if the provider corrects the claim or provides additional information are known as Soft denials
Top Five Reasons for Denials
The AMA‘s National Health Insurer Report has pointed out 5 main reasons for denials which include:
When Claims have Missing information
When there are Duplicated Claims
When there is Pre-authorization for services
When an Uncovered procedures claim is submitted
When Claims are filed past expiration period
Most Common Reasons for Denials in ABA Setting
When Treatment is being stopped abruptly without notice
When unauthorised hours need to be cut back
When treatment does not conform to the level of care/guidelines
When the patient is overaged to avail the benefit
When the patients cognitive abilities are too low to avail benefit
The Most Effective Way in Managing of Denials in ABA Setting is
One should rely on available data to help analyze the RCM process
Identify and attack the root cause where denials are happening
Pay attention at the beginning when patient registration and prior authorization are ongoing.
Incase of insufficient documentation then process needs a structural improvement
Staff should be well trained to know appropriate codes, to avoid coding and billing errors
Payers behavior would be to identify root cause, and have a solution in effective solution in its place
Each department needs to act responsibly as Denials affect every part of your organization.
DM or Denials management in ABA is directly proportional to growth in Healthcare organizations; it ensures better cash flow and reflects best practices as well.
A good understanding of the denials process and a well thought out plan and integrating the power of RPA and data analytics in the RCM module will ensure any ABA practice to better handling of the denials process. Hence at Amromed LLC, we pride that our team of experts do a comprehensive study and understand the ABA insurance eligibility verification process prior to the initiation of services.