The first stage of the engagement was a comprehensive analysis of the hospital’s existing denial data.

The objective was to identify both external payer-related causes and internal process-related causes so that the appropriate corrective actions could be developed.

External Reasons for Denial

The team initially compiled reports of denied claims and organized them according to payer-related reasons.

This allowed the team to identify recurring payer patterns and determine which denial categories required further investigation.

The denials were then separated according to the reasons provided by individual payers, creating a clearer picture of where the hospital’s reimbursement process was experiencing problems.

Types of Denials

The next step was to analyze the different types of denials.

Categorizing the denials made it possible to determine what type of corrective action was required for each group rather than treating every denied claim in the same way.

This analysis also provided a foundation for the subsequent denial-management roadmap.

Internal Reasons for Denial

Payer responses alone do not always reveal the underlying process issue responsible for a denied claim.

For this reason, Medientsky Billing conducted an internal review to identify problems originating within the hospital’s own billing and documentation processes.

Coding

The review found that more than 70% of the denials were associated with incorrect codes.

This made coding one of the most significant areas requiring corrective attention.

The finding highlighted the importance of reviewing coding accuracy as part of the denial-management process rather than focusing exclusively on payer-side issues.

Workflow

The hospital also had workflow gaps that contributed to delays in claim submission and claim logging.

According to the case study, these workflow issues accounted for 4% of claim denials.

The review therefore included the movement of information through the billing process and identified areas where interruptions or delays could contribute to unsuccessful claims.

eClinicalWorks EHR

OrthoGen Care was using eClinicalWorks as its EHR system.

Although the system was considered feasible for the practice, the review found that some in-house users were not sufficiently familiar with the EHR.

According to the case study, this lack of EHR proficiency contributed to 10% of denials.

The finding demonstrated that having an appropriate EHR is only one part of an effective billing workflow. Users also need to understand how to use the system correctly within the revenue cycle.

Documentation

The review also identified documentation problems beginning at several points in the patient and billing workflow.

These included:

• Appointment scheduling
• Patient and encounter data creation
• Charge entry
• Clinical documentation

Improper or incomplete information across these stages contributed to 16% of claim denials.

Because documentation is closely connected to coding and claims submission, correcting these issues was an important part of the overall denial-reduction strategy.

The Phased Denial-Management Approach

Once the analysis was complete, Medientsky Billing developed a phased roadmap designed to address the identified denial categories systematically.

1. Denial Segmentation

The denied claims were categorized according to the action required.

The categories included:

• Hard and soft denials
• Denials requiring attachments
• Denials requiring appeals
• Denials associated with a specific faulty process

This segmentation helped ensure that each denial was directed toward the appropriate resolution path.

2. Remedial Action Plan

A corrective action plan was then developed according to the denial category.

The plan included defined:

• Timeframes
• Staff responsibilities
• Goals
• Workflow requirements

This created a more structured approach to denial resolution and helped organize the work around specific objectives.

3. Workflow Troubleshooting

Before the new workflow was fully implemented, troubleshooting was performed to identify potential interruptions.

The objective was to address workflow problems before they could interfere with the denial-management process.

4. Quality Checks

Quality checks were incorporated throughout the denial-management process.

Each stage was reviewed to help ensure that corrective actions were being completed appropriately and that errors were not carried forward into subsequent steps.

5. Peer Review and Documentation Compilation

The final stage involved reviewing erroneous claim components and compiling the required claim and supporting documentation.

This helped ensure that claims requiring additional documentation or correction were prepared appropriately before further action was taken.