Mastering Denial Management: Key Differences Between Denial Included and Bundled Denial and Why They Matter

 In Revenue Cycle Management (RCM), denials refer to claims that are not reimbursed by the insurance company. Denials can be classified into two categories: denial included and bundled denial.

Denial included refers to claims that are denied for a specific reason or service provided. For example, a claim might be denied because the insurance company considers a particular treatment or service to be unnecessary, or the documentation does not support the medical necessity of the procedure.

On the other hand, bundled denial refers to claims that are denied for multiple reasons. In this case, there might be multiple services provided in a single claim that are denied for different reasons. For instance, a claim might be denied because of incorrect coding or a lack of medical necessity.

The primary difference between denial included and bundled denial is that in the former, the denial reason is specific and related to a particular service, while in the latter, the denial can be related to multiple services or reasons.

To manage denials effectively, RCM teams need to identify the reasons for the denials and develop strategies to resolve them. For denial included, RCM teams may need to review the documentation and resubmit the claim with additional information or clarification. For bundled denial, RCM teams may need to perform a root cause analysis to identify the reasons for the multiple denials and develop a plan to address them.

By effectively managing denials, healthcare organizations can improve their revenue cycle performance, reduce the risk of financial losses, and enhance patient satisfaction by minimizing the need for patient billing.