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Healthcare Denial Management Services

Identify, Manage, Monitor, and Prevent

Denial rates in healthcare claims vary widely, with estimates ranging from 5-25%, reflecting industry challenges and lack of standardization. Wise Medical Billing denial management services proven legacy and expertise are instrumental in minimizing denials, appealing rejected claims, and optimizing revenue recovery. Our commitment to excellence helps healthcare providers navigate denial uncertainties and achieve greater financial stability.

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What is Denials Management Service

Healthcare denial management is a critical process that entails pinpointing the causes behind medical claims denials and implementing strategies to minimize them. A crucial aspect of this endeavor is the proactive implementation of tactics to enhance the rate of initial claims reimbursement.

To achieve effective denial management, it's imperative to consider the following factors:

  • Complete visibility into the performance of a healthcare practice through in-depth analytics and reporting
  • Identifying the reasons for denials of claims
  • Reduction in the overall number of claims denied and increase in the number of claims paid
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Root Cause Analysis

Effective denial management services in medical billing commences with a comprehensive root cause analysis. The most efficient approach to mitigate financial losses stemming from denied claims is to proactively prevent their occurrence. Below are some of the common reasons for claim denials across various medical specialties:
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Missing or incorrect information
There are a variety of reasons why this may occur, including blank fields (e.g., Social Security number or demographic information) or incorrect plan codes, to coding errors such as missing modifiers.
Duplicate claims
Submitted claims for a single visit on the same day by the same provider for the same patient.
Provider out of network
In the event that the services are provided by an out-of-network provider, the payer may deny the claim in whole or in part.
Prior authorization
A claim may be denied if prior authorization is not obtained prior to the service being performed. The payer continues to update the list of services that require prior authorization.
Coordination of benefits
If a patient is covered by more than one health insurance plan, claims can be delayed and even denied until the patient's coordination of benefits is updated.
Medical necessity requirements not met
When a healthcare service is medically unnecessary, the policy does not cover it, and the payer disagrees with the physician about the type of treatment you need for your condition.
The procedure not covered by payer
In most cases, this can be avoided by reviewing a patient's insurance policy or contacting their insurer before submitting a claim. The payer may deny a claim if a procedure performed is not covered.
Exceeded timely filing limit
When a claim is filed outside the payer's required days of service, this should be considered when reworking rejected claims.
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Get Perfect Denial Management with WMB

Assuring that your insurance claims are complete, accurate, and able to be processed by the insurance company is a significant accomplishment on its own, since it prevents your organization from potentially revenue losses.

Here are four more reasons you want to implement Wise Medical Billing Perfect Denial Management in your practice:
  • To avoid future denials, the process can help identify areas that require improvement.
  • As part of our denial management plan, we track, prioritize, and appeal denials based on case citations and state/federal statutes that support your entity's appeal.
  • The collection and analysis of denial patterns provides insight into their root cause, enabling the denial management team to devise a permanent solution for these types of problems.
  • By using our denial management service, a healthcare organization can also collect more candid information to support an appeal, which may result in a higher claim payment.

GET A QUOTE FOR OUR PERFECT DENIAL MANAGEMENT SERVICE

Reach out to our experts at WMB for High Quality, Clinically Focused and Cost-effective Denial Management Service

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Benefits of the A/R and Denial Management Process

With our full suite of A/R and denial management services, we provide the following benefits to our clients:
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Be focused on resolving claims
Our primary focus is on resolving the claims, rather than simply obtaining information regarding the status of the claims.
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Filling Appeals
Our company analyzes and prepares denial reasons, prepares appeal letters, and refiles claims by attaching clinical documentation and submitting them via fax appeals in the format required by the payer.
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Process Automation
As a result of our improved adoption of web portals to obtain claim status online, we have reduced the effort required to check claims status.
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Workflow automation.
Insurance companies must answer a set of questions related to each claim status code in order to resolve the claim's issues. In order to improve the quality of documentation, we have defined our claims follow-up work queues using web-based workflow systems.
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Dashboards and metrics
The use of multi-variate reports enables us to gain a clear understanding of our accounts receivable and focus our efforts on resolving these accounts
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Improving collections and reducing days in A/R
Our clients see a minimum of 20% reduction in days in A/R and improved collections by about 10-15%.
Wise Medical Billing stands as the preferred choice for healthcare service providers nationwide, offering comprehensive Denial Management and Denial Prevention solutions.

At WMB, we firmly believe that the Right people, combined with the Right process, can conquer any challenge. That's why we are the Wise Choice for Healthcare Providers.

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Injection & Pain Management

We provide compliant billing for foot injections, nerve blocks, and pain management procedures with accurate documentation and proper modifier usage.

Advanced Treatments

We handle advanced podiatric treatments with proper prior authorization management and comprehensive clinical documentation for high-value services.

Nail & Skin Procedures

We ensure accurate coding for nail debridement, callus removal, and skin lesion treatments with proper medical necessity justification and frequency compliance.

Surgical Procedures

We manage complex podiatric surgeries with accurate modifier usage, justified gaps between claims, and transparent timeframe documentation for all procedures.

Diabetic Care Management

We coordinate diabetic foot care services with proper medical necessity documentation and systematic condition correlation for comprehensive treatment.

Orthotic Services

We provide specialized billing for custom orthotics and devices, ensuring proper HCPCS and ICD-10 code pairing to justify fitting and delivery documentation.

Routine Care & Diagnostics

We handle routine foot care according to strict medical necessity criteria, ensuring precise paperwork and accurate coding for debridement and mycotic nail care, with proper frequency documentation.

Wound Care Partnerships

We provide accurate code coordination to prevent overlapping, ensure transparent tracking for pre- and post-surgical services, and deliver complete operative notes with reduced errors.

Graft & Skin Substitute Procedures

We select accurate application and graft codes based on location and wound size, audit surgical documents to ensure correct Q-code pairing for procedures and supplies, and assist in navigating state-specific Medicaid nuances through proactive prior authorization.

DME Billing

Robust compliance for orthotics, diabetic shoes, walking boots, and offloading devices. We ensure that certified coders are used for accurate coding and a perfect match for every claim. We evaluate the signature requirements of every payer and employ proactive strategies for expedited prior authorization.

Injection Therapies

We handle foot injection procedures with accurate MCO compliance, ensuring proper documentation and modifier usage for maximum reimbursement in the NY market.

Nail & Skin Care

We provide compliant billing for nail debridement and skin lesion procedures, meeting eMedNY-specific documentation requirements and ensuring proper medical necessity justification.

Advanced Treatments

We manage advanced podiatric treatments with NY-specific requirements, ensuring proper Q-code usage, comprehensive clinical packets, and expedited prior authorization processes.

Diabetic Care Management

We coordinate diabetic foot care services with wound care partnerships, ensuring proper documentation and transparent billing coordination for all involved providers.

Surgical Procedures

We handle complex podiatric surgeries with MCO coordination, ensuring accurate service sequencing and proper documentation to prevent overlapping claims and denials.

Orthotic Services

We provide specialized eMedNY-compliant orthotic billing with precise HCPCS coding, accurate ICD-10 pairing, and comprehensive modifier knowledge for maximum reimbursement.

Routine Care & Diagnostics

We ensure eMedNY compliance for routine foot care services with systematic condition documentation, proper modifier alignment, and comprehensive medical necessity justification for all procedures.

Graft & Skin Substitute Procedures

We prepare comprehensive clinical packages for fast approval, ensure thorough compensation for graft products and application, and prevent claims denials through accurate coding and correct submission.

Wound Care Partnerships

We provide accurate code coordination to prevent overlapping, ensure transparent tracking for pre- and post-surgical services, and deliver complete operative notes with reduced errors.

DME Billing

NY Medicaid’s top coverages include diabetic shoes and inserts, ankle-foot orthoses, braces, and custom-molded orthotics. We ensure eMedNY compliance through precise documentation, proper ICD-10 coding, and in-depth knowledge of modifiers to prevent denials.

Robotic Procedures

We deal with complex billing for radical prostatectomy, partial nephrectomy, and cystectomy by elaborative documents for the used devices. Our accurate codes and modifiers ensure successful approvals.

Telehealth

Our coders ensure accuracy for pre-op consultations, follow-ups, and LUTS/OAB management. Our optimized POS and use of modifiers have lower denial rates, as we demonstrate their necessity with clinical documents.

Urodynamics & Diagnostics:

We handle multi-channel involvement and billing complications with detailed CPT/ICD pairing. Our proactive prior authorization handling and expert claim structuring ensure error-free approvals.

Cystoscopy & Endoscopy:

We capture every detail and require evidence to ensure a smooth claim approval for office-based and hospital-based endoscopic procedures. We offer robust billing claims for biopsies and stone removals.

Lithotripsy (ESWL) & Stone Management:

We understand the complex bundling of ESWL, URS, and stone procedures, including device charges, anesthesia, and supplies for ongoing care. This in-depth knowledge ensures coding accuracy for each component.

Prostate Procedures & Biopsy:

We offer meticulous billing for targeted biopsies and imaging-guided prostate procedures, ensuring proper coordination of involved pathology and detailed capture of all allowable charges.

Implants & Prosthetics

We strictly follow the payer’s rules for high-value penile prostheses and testicular implants, ensuring proper coverage for device charges. Our coders ensure proper coding pairs, transparent vendor contracts, and logs for implants.

Pathology & Imaging

Our team possesses in-depth knowledge of the working principles of pathology and imaging centers. We collaborate with service providers to obtain accurate clinical information, ensuring that we capture all allowable charges.

Botox & Neuromodulation

For these complex services, we provide thorough coverage by handling prior authorization approvals and ensuring coding accuracy for both trial and permanent procedures. Our modifier’s accuracy provides high compliance with diverse payer requirements.

DME & Catheter Supplies:

We provide streamlined billing claims for catheter and drainage bag supplies, ensuring smooth and timely payment collections. Our proof-of-delivery and proactive SOPs save practices from financial loss.

DME & Catheters

We handle catheter supplies, ongoing maintenance claims, and billing for incontinence aids. We complete clinical documents with proof of need, supply evidence, and other supporting elements according to Medicaid requirements.

Pathology & Advanced Imaging

Outpatient labs and imaging services face facility-based billing cuts due to poor classification. We manage all complexities with professional splits and ensure compliant claims for radiology reads and pathology services.

Botox & Neuromodulation

We perfectly align the trial with a permanent implant and explain all stages with accurate codes. Our precise and error-free claim submission ensures maximum reimbursement for all elements.

Implants & Prosthetics

We offer support for commercial or Medicaid billing claims through transparent device tracking, fair vendor contracts, and compliant pre-auths, resulting in the successful implantation of penile prostheses, urinary sphincters, or slings.

Prostate Procedures & Biopsies

Pairing of biopsies with MRI-guided prostate means additional care for billing documents. These coordinated services required accurate pathology linking, ensuring that our robust component captures the necessary information.

Lithotripsy & Stone Procedures

We offer coding accuracy from ESWL to ureteroscopy by managing compliant documents for anesthesia, professional components, and prior authorization for such high-value services.

Cystoscopy & Endoscopic Interventions

Our technical expertise ensures billing accuracy for stent removals, cystoscopy, and facility-based endoscopy procedures. We separate each component of treatment to bring payment for all.

Urodynamics & Pelvic Testing

We justify the clinical necessity for urodynamic services. We offer hands-on support for authorization, ensure claims accuracy with diagnosis justifications, and document compliance for revisits.

Telehealth Evaluation Services

We have current information about eMedNY and MCO policies, ensuring coding accuracy with proper place-of-service designations, relevant modifiers, patient consent forms, and explanations of rendered services.

Robotic Procedures

We cover high-value procedures such as prostatectomy and nephrectomy, among others, by accurately documenting device costs in clinical documents and justifying their necessity under APG and facility-based insurance rules.

Pathology & Imaging Coordination

We resolve coding conflicts for these pairing services and ensure a justified coordination in documents to prepare a clean claim with reduced denial risks.

DME & Catheter Supply Managemen

The Medi-Cal and commercial payers have strict compliance requirements for DME. We streamline your claims with transparent usage tracking to ensure quality care and justified reimbursement.

Botox, Neuromodulation & OAB Treatments

We simplify the staged billing process for trials by managing prior authorization, the device’s paperwork, and submitting claims to accurate insurers to make it more manageable.

Implants & Prosthetics

We expedite your operation by handling authorization and vendor contracts, managing paperwork for pre-approvals, ensuring coordination, and maintaining inventory logs for stents and penile implants.

Prostate Procedures & Biopsies

Our experts accurately sequence the complex billing claims for MRI-fusion biopsies, prostate services, and imaging pairings across various payers to ensure maximum reimbursement for practices.

Lithotripsy & Stone Procedures

We navigate the complex process through accurate coding, transparent anesthesia reports, and the use of durable equipment, resulting in maximum coverage for every service.

Cystoscopy & Endoscopic Interventions

We capture each detail about scope procedures, stent placements, and biopsies performed in facility or ASC settings to prepare compliant claim documents.

Urodynamics & Pelvic Testing

We understand the unique compliance requirements, from bladder studies to pelvic floor testing, which prove the clinical necessity to ensure robust prior authorization and successful billing claims.

Telehealth Evaluation Services

California has broader telehealth services, with high Medi-Cal reimbursement for these services. We cover modality, consent, and explain facility settings so that you can get maximum advantage from every allowed charge.

Robotic Procedures

We precisely document robotic-assisted surgeries, negotiate with insurers, reflect the procedure’s complexity, and complete all paperwork in accordance with payer requirements to ensure a justified payment.

AB 72 – Surprise Billing Law

For podiatrists providing surgical services in out-of-network facilities, California’s AB 72 limits balance billing. Navigating this requires precise billing strategies.

Prior Authorization Hurdles


Increasingly, California payers require prior authorizations for DME, orthotics, skin grafts, and advanced wound care procedures. Failure leads to non-payment.

Workers’ Compensation Complications

California’s Workers’ Compensation system demands strict adherence to the Official Medical Fee Schedule (OMFS) and highly detailed documentation—especially for podiatric injury care, fracture management, and surgical interventions

Complex Wound Care & Skin Graft Billing

Podiatrists collaborating with wound care centers for diabetic ulcers, pressure sores, or limb salvage procedures face frequent denials related to skin substitute grafts (e.g., Apligraf®, Dermagraft®) and advanced wound treatments like NPWT (vacuum therapy).

Medi-Cal Restrictions

Medi-Cal limits podiatry services unless directly related to chronic disease management. Denials are common without proper coding and documentation.

Routine Foot Care Scrutiny

California insurers, including Medi-Cal and major HMOs (Kaiser, Blue Shield CA), often classify foot care (like nail debridement and callus removal) as non-covered unless medically justified by conditions like diabetes or peripheral vascular disease.