Increasing claim write-offs and decreasing success in denial appeals amplify the already sad state of the financials of hospitals and healthcare systems caused by the current labor shortage and trend of declining reimbursements. Shouldn't hospitals be focusing on denial prevention rather than denial recovery?
Pursue every denied claim
Healthcare providers must put strategies to pursue each denied claim and establish a workflow that categorizes each claim by reasons for the denial, including complex clinical denials and low-dollar claims. Historical data points on the rate of success by payer and denial reasons will help you create a customized denial appeal process for the institution's type of services and the payers they deal with often.
Templatize your denial appeal process
Learning from past denial appeals will help you create a better process for appealing similar claims. Maintaining a database of successful requests by payer and denial reason will help you craft an effective denial appeals process, saving you resources and time in the future.
Focus on clinical denials
Clinical or coding denials require a focused appeals strategy that relies on expertise in the specific specialty. Involving expert medical coders who possess the knowledge specific to the specialty will help you provide the correct supporting evidence and arguments in your clinical denial appeals. Talented coders in discussions with the clinicians can help establish medical necessity for the specific procedure and improve your chances of getting reimbursed.
Establish a denials prevention program
Denials and appeals team members must create a construct to work with coders, clinicians, and front-end revenue cycle personnel.
Document the root cause of each denial and discuss them with your front-end and mid-cycle RCM teams on how to avoid getting claim denials for the same reasons again.
Periodic discussions and review sessions with the physicians will improve the team's knowledge of specific procedures and help them craft successful arguments when filing appeals. Recognizing that over 60% of denials stem from avoidable causes or actions, the group can adopt an 80:20 analysis to create solutions for the top denials and avoid costly mistakes.
Apply automation and analytics
Establishing predictive and intelligent workflows can help the team specialize in payer-specific denials issues and create specific templates for effective denial appeals, improving the efficiency and effectiveness of the team. Workflow automation can help you optimize human effort, and robotic process automation can help you create appeals in payer-specific formats. Analytics will help you appeal denials that will yield maximum revenue recovery.
Measure the success
As you improve the appeal win rate and take remedial actions to eliminate the cause of claim denials, you will automatically shift your focus to denial prevention. Empower your team with automated reports that help them understand the cause of denials and take specific actions to eliminate the root cause. Institutionalizing the denial rate measurement, analyzing the cause, and eliminating the root cause will help you translate learnings into a denial prevention strategy.
Access Healthcare's Denial management and prevention program combines our process knowledge, technology, and frameworks to help you reduce denial rates, improve reimbursements, and accelerate cash flow. We leverage our process automation, medical coding, and clinical documentation expertise to help you develop a long-term denials strategy that focuses on preventing rather than managing denials and enables you to recover more revenue. To learn how we can help you overcome your denial management challenges, contact us at: info@accesshealthcare.com or call us at +1 844 533 1307