Client Success Story

$240K+ Recovered through Prompt Denial Management for a Specialized Mental Health Practice


A Specialized Mental Health Practice Focusing on Psychiatry and Neurology

Based in California, the client's practice is dedicated to treating a wide range of psychiatry and neurology related conditions, including depression, anxiety, bipolar disorder, schizophrenia, epilepsy, and Parkinson's disease. It deals with twenty insurance providers, including Medi-Cal managed healthcare (handled by respective counties) and commercial insurance companies.

Despite its expertise in mental and behavioral health services, the practice encountered significant challenges in the claims submission process. This led to high denial rates and substantial lost revenue.

Project Requirements

Streamline Claims Submission Process and Reduce Denial Rates

The client's medical billing team was struggling to keep up with the varied claims submission requirements of twenty insurance payers. Delayed and unpaid claims were impacting their cash flow and the overall financial stability of the practice, requiring efficient claims processing and follow-up.

They needed-

  • The latest updates and specific requirements of each insurance provider
  • Review and resolution of the currently denied claims and revenue recovery
  • Standardized claims submission processes to decrease claim denial rate and ensure timely denial management

Considering the requirements, we offered denial management services to this client, with claim submission management and RCM audit support as well.


Key Issues the Client Faced in Denial Management

The denial management challenges of this healthcare service provider were as follows:

  • The client had over $300,000 tied up in denied claims for over 2000 cases
  • A high percentage of claims were denied (over 35%), leading to significant revenue loss
  • The success rate of appeals for denied claims was below 38%
  • No payments had been received from the county for over seven months

We also had to manage varied submission requirements and policies of Medi-Cal managed care programs and other insurance companies (20+). As discovered in an audit of the client's revenue cycle management process, most claims were denied because the required information or compliance with new policies was missing or incorrect, especially in the case of Medi-Cal managed healthcare programs.


An Effective Approach to Denial Management, Claim Processing, and Revenue Cycle Management


Dedicated Team Setup

We allocated a specialized dedicated team of 15 members to address the client's challenges. This team consisted of-

  • Project Manager- Oversaw the entire project, coordinated team efforts, and communicated with the client
  • Billing Specialists- Responsible for handling claims submission, identifying payer-specific requirements, and resolving billing discrepancies
  • Analysts- Conducted in-depth analysis of billing data, identified trends, and provided insights for process improvement.
  • Credentialing Expert- Ensured that the client's facility met the insurance payer's criteria to provide healthcare services to patients, ensuring smoother claim processing
  • Denial management Experts- Focused on denial cause identification, made sure all team members double-checked their work to avoid unnecessary denials, improved documentation practices, ensured compliance with payer guidelines, and implemented training programs for staff
  • County Department Liaison- A dedicated team member responsible for managing interactions with the County Department and ensuring timely payments

Denials Analysis and Root Cause Identification

Our team conducted a detailed review of all denied claims to categorize and quantify the reasons for denials, such as missing information, insufficient pre-authorization/eligibility issues, or errors in medical coding & charge capturing. We mapped out the entire claims submission process to identify bottlenecks and areas prone to errors and implemented corrective action plans. This included updating processes and enhancing documentation practices.


Claim Verification for Eligibility Issues

A significant number of claim denials were due to patients not being eligible for coverage at the time of service. We acquired login credentials for the websites of all insurance providers to access real-time eligibility information. Dedicated staff were assigned for insurance eligibility verifications and pre-authorizations to handle eligibility checks, ensuring they were performed accurately and efficiently. This reduced the time to check and confirm patient eligibility, leading to faster and more accurate claim submissions.


Denial Management

With the objective to reduce the volume of denied claims and recover lost revenue, we categorized denied claims based on denial reasons and financial impact, prioritizing high-value claims for immediate action. The appeals were enhanced with detailed documentation and evidence were included in each appeal to improve the success rate. Our team monitored the status of denied claims in real-time, allowing for quick identification and resolution of issues.


Improvement in the Claims Submission Process

For this client, poor claim processing was the primary reason for so many claim denials. Our RCM specialists implemented standardized protocols for claims submission and provided comprehensive training to the client's in-house billing team on the latest medical coding standards, documentation practices, and payer-specific requirements. We also recommended and implemented an advanced billing software to automate their claims submission process, ensuring real-time compliance with payer guidelines and reducing manual errors.


Evaluation of the Client's Medical Billing and Coding Process

While all medical billing and coding require precision and adherence to standards, billing for psychiatry and neurology services presents unique complexities. CPT codes for psychotherapy sessions, EEGs, and neurological tests are highly specific and time-based. Many psychiatric services are billed based on the time spent with patients, necessitating precise tracking and documentation, as opposed to general hospitals where services are billed based on procedures performed.

The client's practice was under a higher risk of claim denials because they had not invested much time into understanding the complexity of coding and documentation requirements for their niche. We aligned medical coders specializing in the psychiatry and neurology fields to help the client navigate the appeals process for denied claims, often needing detailed justifications and additional documentation. This mini-team continues to handle the client's medical coding & charge capturing process till date.

Project Outcomes

Recovered over $240,000 in previously denied claims

Increased the success rate of appeals for denied claims from below 38% to over 70%

Reduced the TAT for eligibility checks by 40%, leading to more timely and accurate claim submissions

Achieved 95% compliance with Medi-Cal and other payer-specific requirements

20% higher claims processed accurately and timely each month

TAT of all multi-level claim submission tasks reduced from from 4 days to 2 days (average)

Clean claims ratio improved to over 95%


Recover the Capital Tied in Denied Claims with SunTec India

Our HIPAA-certified RCM company helps tackle denial management challenges of healthcare service providers across the globe. In addition to denial management services, we also offer complete revenue cycle management services as well as standalone claim submission management, invoice processing, payment posting, medical coding and billing services, and charge entry services. You can also get healthcare BPO support for other back-end activities.

Reach out to our denial management team for a free consultation.