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Authorization and Getting Paid, lesson 3 of 4
A Denial Is Almost Always a Document Problem
Most denials are not a judgement about the dentistry. They are a statement that the paperwork did not establish something. Treated one at a time, they are admin. Sorted and counted, they are the best free diagnostic a practice has.
- Read first. The reason, not the amount
- Three buckets. Fix and refile, appeal, or change what we do
- Count them. By reason code, monthly
- The real win. Stopping the repeat, not clearing the one
Sort Before You Work
Denials fall into three piles and they need different people. Something was missing or wrong and can be corrected and refiled. Something was judged and you disagree, which is an appeal. Or the program is telling you that what you did is not covered the way you thought, which is a change to how you plan.
Working the pile in date order mixes all three and wastes the most skilled person in the room on the easy ones.
The third pile is the important one and the easiest to miss, because each individual case looks like bad luck.
Watch the Clock on Every Pile
There is a window for refiling a corrected claim and a separate window for appealing. Both are set by the program and both are unforgiving, because they are administrative deadlines rather than guidelines.
A denial that sits in somebody's tray for a month has often already lost. That is the argument for working denials weekly rather than when there is time.
Get the current windows from your state program and put them somewhere the person working denials can see without asking.
Count Them, or You Will Keep Fixing the Same One
Once a month, count denials by reason rather than by dollar. The dollar view says which ones hurt. The reason view says which ones you are causing.
A reason that appears twenty times is a process problem with a single cause upstream, usually at the front desk or in how a procedure is documented. Fixing it once removes twenty denials a month permanently.
Share the count with the whole team rather than only with the person who works them. The cause is nearly always somewhere other than the desk where the denial landed.
The Ones That Are Telling You Something
A run of denials on a procedure you do often usually means the criteria are not what you think, or your documentation has drifted from what it was when the approvals were coming through.
A sudden run of denials across everything, with an unfamiliar reason, is worth treating as urgent. That pattern can mean an enrollment or credentialing problem rather than a claims problem, and those get more expensive the longer they run.
A denial for other coverage paying first is an eligibility check that did not happen or was not read. That one is entirely preventable at the front desk.
Before You Spend a Dime
Is it worth appealing small amounts?
Sometimes not individually, and almost always worth counting. Twenty small denials with one cause are not a small problem.
Who should work denials?
Somebody who can see the pattern, not only clear the queue. The job is part clerical and part diagnostic, and practices that treat it as purely clerical keep paying for the same mistake.
How often should we look at them?
Weekly for the work, monthly for the count. The windows are too short for a quarterly habit.
Next Problem to Solve
- Reading Your Own Aging ReportNext in the course. The one report that tells you whether the practice is actually being paid, what the shape of it means, and the trap of judging a program practice by private practice benchmarks.
- Prior Authorization Is the Skill the Practice Runs OnRelated. Approval before treatment is the step that decides whether work gets paid for. What a reviewer is actually looking at, and how to submit so it goes through the first time.
- Staying Enrolled, and the Lapses That Stop PaymentRelated. Enrollment is not a one time event. What has to be kept current, what happens when it is not, and why the symptom shows up months after the cause.