Trying To Beat Denials Before They Happen

Railing against the health insurance fates is just not Jayne Kroner’s style.

Kroner, VP of business development at the Cirius Group, a California health care financial consulting firm, said she’d rather deal with the reality of insurance denials.

“If you have the right mindset to know it’s a fact of life, it becomes like a wellness program for your hospital and physician claims,” Kroner said. “You want to prevent denials.”

Kroner is part of a panel that’s meeting today in a Modesto hospital conference room, organized by the Northern California chapter of the Healthcare Financial Management Association, to talk about all of the potential hang-ups and barriers to getting paid by insurance companies, and how to avoid denials before they happen.

“Say you’re a surgical patient, and your right foot’s broken,” she said. “And you go into the operating room and get that done, but say the OR forgets to put in a charge code. So even if you have a diagnosis code entered, that’s going to be a denial.”

Same thing if you have a charge code but no diagnosis code — and the same thing happens with any number of technical errors. Insurance companies issue a lot of technical denials, she said.

“I’d say they’re of equal comparison to clinical denials, in terms of number of patients and number of claims,” she said. And when those claims get denied for technical reasons, that starts a reapplication process that can be extremely costly for physicians and hospitals, she said.

“You have to regenerate information, give proof of validation, you have to provide medical records, it’s an incredible amount of administrative work,” Kroner said. “Really, it’s a huge delay tactic, as well, because the longer they can hold that money in their pocket, the better it is for them. But it loses the hospital a lot of money.”

So by setting up systems that monitor the usual sticking points in technical denials, medical institutions can end up saving time and money, Kroner said.

“I’ve been doing this for 25 years, and when I first started there were occasional denials of care,” Kroner said. “But it has expanded, expounded, exploded. To me, the devil’s in the details, and it’s these kind of details that are really limiting hospitals’ financial viability.”

The Healthcare Financial Management Association will hold similar forums over the next few months in Fremont, Monterey and Sacramento.

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