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Being Proactive in the Denial Management Process

Claim denials can pose a significant financial burden for healthcare providers, regardless of their size. However, avoiding claim denials is challenging; therefore, having a comprehensive plan and proactive approach is crucial.

What is Claim Denial? 

When patients receive healthcare services, third-party payers such as insurance companies or governmental programs cover some or all of the bill's costs. The healthcare provider submits a claim to the payer during the medical billing process, which may be accepted, paid, rejected, or denied. Visit our blog to understand healthcare automation tools that improve denial management.

Rejections occur when errors are identified during the early processing stages, whereas denials happen after claims have been processed. As a result, denials can be particularly challenging to manage, which is why claim denial management is essential.

Claim denials can have a significant impact on healthcare practices and providers, including:

  • - Financial losses: Denied claims result in lost revenue and may cause cash flow problems for healthcare providers.
  • - Increased costs: Resubmitting denied claims and appealing them can be time consuming and expensive, leading to higher operational costs.
  • - Administrative burden: Managing denied claims can be complex and requires additional administrative resources, which may detract from patient care activities.
  • - Reduced productivity: Healthcare providers may need to divert resources from other areas to address denied claims, resulting in reduced productivity.
  • - Patient experience: Denied claims can cause delays in payment and additional billing, leading to patient dissatisfaction and negative reviews. This can have a long-term impact on healthcare providers. 
  • - Compliance risks: Failing to manage claim denials effectively can lead to compliance risks, such as regulatory penalties and reputational damage.

Overall, claim denials can significantly impact the financial health and operations of healthcare practices and providers, making it crucial to have a proactive approach towards denials management. A denials management service with Exela’s PCH Global can improve cash flow, reduce denial rates, and more.


Denial Management in Healthcare | Close up of person working on laptop with papers and a stethoscope resting next to them


Understanding Denial Management

Denial management refers to identifying, analyzing, and resolving claims denials in the healthcare industry. A denied claim is a claim that has been submitted to an insurance company or government payer but is not paid because it does not meet the criteria for coverage or contains errors or omissions.

Denial management involves a systematic approach to identifying the reasons for denied claims, rectifying any errors or issues, and resubmitting them to the payer. It may also include appealing denied claims that are eligible for reconsideration. Effective denial management helps healthcare providers to maximize revenue, reduce operational costs, and improve patient satisfaction. In addition, by analyzing and addressing the root causes of denied claims, offering a comprehensive denial management approach that can identify areas for process improvement and implement strategies to prevent future denials.


Healthcare providers can take a proactive approach to denial management by implementing the following strategies:

Identify common denial reasons: Healthcare providers should analyze denied claims to identify the most common reasons for denials. This can help them develop targeted strategies to prevent future denials.

Educating staff on denial management: Healthcare providers should educate their staff on the importance of denial management and provide training on best practices for preventing and resolving claim denials.

Use technology to streamline processes: Solutions like electronic health records (EHRs) and denials management software can help streamline the claims process and reduce the likelihood of errors and denials.

Conduct regular audits: Regular audits of claims processes can help identify areas for improvement and ensure compliance with regulations. Effective denials management solutions such as PCH Global also analyze and track trends from collected data. 

Develop a denial management plan: Healthcare providers should develop a comprehensive plan for managing denials, including strategies for prevention, identification, and resolution.

Monitor payer policies: Healthcare providers should stay up-to-date on changes to payer policies and requirements to ensure claims are submitted correctly.

Engage with payers: Healthcare providers should establish relationships with payers, communicate regularly to understand their policies and requirements, and promptly address any issues.


Denial Management | Close up photo of person working on laptop with graphs on their screen


Denials Management with Exela PCH Global

Overall, denial management is an important part of revenue cycle management in healthcare. PCH Global offers solutions that ensure claims are paid promptly and accurately, enabling providers to deliver high-quality care to patients. The proprietary PCH Global platform identifies to-be-denied claims before submission. Exela's solution also analyzes suspended or denied claims using root cause analysis (RCA) to avoid recurring issues with claims. 

Exela’s denials management solution automatically categorizes based on the reason and remark codes, enabling a more thorough analysis. The solution demonstrates upwards of 30% of all claim line items denials can be avoided. The platform provides immediate guidance for online correction prior to submission. Our edit engines comb through each claim assessing for Payer-specific edits, SNIP edits, Coding & Billing edits and Compliance edits, streamlining the process into a single, simple workflow, reducing time to complete and improving accuracy. 

By taking a proactive approach to denial management, healthcare providers can improve their revenue cycle management, reduce costs, and improve patient satisfaction. Get in touch to learn more about Exela’s denials management solution.