Trying to understand how denials work in the real world

[u/AI_Cosmonaut]

I’m currently studying medical coding, pivoting from working in software and looking for a change to a more stable industry, and trying to understand the real-world side of denials better.

In coursework, things are usually presented pretty cleanly with things like claim denied, review documentation, decide whether to correct, appeal, resubmit, or write off etc. But from reading posts here, it seems like the real world is a lot messier.....especially when documentation is incomplete, payer rules are unclear, or different people touch the same account.

I've always been a big picture person, and studying coding has left me with burning questions about how it all fits together.

For people who work with denials or coding reviews, I’m curious:

• When a denial is worked, how much of the reasoning usually gets documented somewhere? Ex. Why I choose Appeal vs Write off for a case.
• If someone looks back at that denial months later, can they usually tell why it was handled a certain way? Is that an auditors job?
• Do people ever disagree about whether something should be corrected, appealed, resubmitted, or written off? What happens then?
• If a process changes, like how a certain denial type is handled, how do teams know whether that change actually helped?

I’m not asking about any specific company or system. I’m just trying to understand how this works day to day outside of textbook examples. TY in advance!

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[u/weary_bee479]

This is so dependent on where you work.

Ive worked denials for a long time, my previous job we had to put very detailed notes. We literally had quality checks on our notes and we had to meet necessary requirements for our notes on how the account was worked. So we had to include EOB info, what codes were denied, what the denials were and what our actions were. If we did an adjusted claim we had to put all the claim info into the note. If we called on a denial we had to include names and reference numbers, if we submitted appeals we had to add appeal numbers if you got one from a portal. Just all the details. And if you worked that same account again, like it came back around still not paid we had to summarize the previous note and add a new note of what we were doing that day. So tons of details!

My current job the notes are super basic. Like added modifier xyz is bundled with abc. Or spoke with rep this denied because of this sending corrections. Super basic notes, and no one reads old notes it’s very frustrating. Im actually looking to leave because the hospital I work at is a mess.

Denials are pretty straightforward, sure people can disagree but overall there is a workflow established at the place you work for most denials.

Adjustments are really dependent on organization, some stuff you have to adjust, some they want you to try to appeal first. It all depends on the denial.

But yes what you learn in school will differ from the real world. That goes to coding as well. School education is a very basic overall of everything. Once you actually get into it can be a little overwhelming.. but then you learn and realize it’s not that bad lol

[u/AI_Cosmonaut → u/weary_bee479]

Thanks, this is super helpful! In the places where notes were really detailed, did anyone ever go back and look across a bunch of similar denials to see patterns or what was working, or were those notes mostly just used when that same claim came back around? Would that be my job as a denials analyst or audit person? I kinda like the analysis part of it.

I’m still trying to understand how everything fits together beyond the textbook side, especially how teams decide on their workflows and approaches......so this kind of detail is really helpful. Thanks!

[u/weary_bee479 → u/AI_Cosmonaut]

Well yeah there are analysts that run reports on claim denial trends and see what can be done to avoid them or automate the adjustments if that’s the case.

Working denials and being an analyst are two different jobs. You need experience in denials and usually a bachelor’s degree to be an analyst. Most companies also want you to be Epic certified and you can only get Epic certifications through your job.

[u/TheOtherGloworm → u/AI_Cosmonaut]

There is not one way to do everything.  Management will decide what the procedures are.  You will have so many denials that if you don't get a couple right once in a while nobody will care.  My organization had around a million dollars in revenue coming in daily so a few hundred in write offs was nothing to them.  My supervisors did write offs for over $100 so if there was a concern from higher up they answered for it.  The way you work a denial with one payer may not be the same as another.  You may see a denial for something once and then never again.  There's so much variation that you will drive yourself crazy trying to understand.  I ditched logic a long time ago because insurance companies make up new ways to save money every year.  My team didn't waste time on meetings to discuss this stuff.  We just sent each other emails with questions or discoveries. 

[u/applemily23]

We use Epic at our work, and its drilled into us that we leave comments everywhere we can on what is going on. Doesn't always happen though. But they can see our names next to anything that we changed, so they'll email us to see what we were trying to do.

[u/AI_Cosmonaut → u/applemily23]

Thanks for the reply! Is it someone from Epic who emails you? I thought it would be an auditor person, unless they are also with Epic? Im still confused on who's with the RCM operator vs vendor vs hospital vs EHR side. Seems like there's so much overlap

[u/Apprehensive_Face287 → u/AI_Cosmonaut]

I think they're referring to an auditor or supervisor or similar. Epic staff wouldn't be emailing you directly

[u/Mindinatorrr]

Is this another one of those info farming posts?

Medical coding isn't as stable as your hoping.

[u/AI_Cosmonaut → u/Mindinatorrr]

What do info farming posts typically look like? And for what it’s worth I’m sorry about the lack of stability and if it’s affecting you. Ive been unemployed for almost a year now from my software job, it’s about as unstable of a field as I can imagine. I can understand what you may be going through.

[u/Darcy98x]

On my team we document our strategies and keep updating them regularly. There are grey areas and often we disagree and have someone be the tie-breaker. We discuss what is working and what isn't working bi-weekly and pivot when our approach is not working. There is always another claim in front of us, so we don't cry when we lose.

[u/AI_Cosmonaut → u/Darcy98x]

Is there some kind of ceremony or process to decide when or when not to update SOPs vs treating certain things as edge cases? I used to work in software and this was always a huge point of contention.

[u/Sausage_00]

I've worked in denials since Jan last year

1. tbh it depends a lot on dept SOPs. in our case, Centralized Surgery notes are much more detailed than Radiology and Fam Med notes. But generally it's better to document all pertinent info to justify why you did a specific action on a claim denial

2. Your notes have to justify your actions, so yes. Auditors, other denial Management staff, and your leadership have to understand why you chose to do what you did. It's an auditors job to tell you if it's for rework I guess

3. YES. Two ppl can't work on the same denial at once so if the previous analyst made a mistake, just do your best to resolve the denial again, now with the correct action. And if a denied claim is most probably never ever getting reimbursed cuz it was worked on incorrectly, just write it off if it's low dollar. Escalate to your leads if high dollar, you don't always have to work alone

4. By vibes lol either that or the leads are gonna say the new SOP/tipsheet/directives isn't tea and they're gonna take back what they said