The medical insurance claims denial process is, by nature, cyclical and complicated. In today’s value-based healthcare environment, management must not only strive to meet the medical needs of patients but also implement guidelines and enhance internal collaboration to prevent denials and maintain revenue.
While claim denials represent one of healthcare’s largest revenue cycle bottlenecks, identifying the source of denials has never been a top priority for providers. Why? Along with the transition to value-based care, providers must adapt both clinical professionals and patients to advances in technology, diagnostic criteria, and payment processes. Therefore, in the whirlwind of new-age healthcare, analyzing sources of lost revenue and strategizing models for improvement can seem like a daunting, time-consuming task.
The solution to enhancing the timeliness and efficiency of your claims management processes begins with understanding how various reports and analytics tools can directly benefit the denial workflow. In developing a plan to leverage data analytics, one must consider the different types of available reports and their coinciding benefits. Interactive reports, analytics dashboards, and claim-by-claim data each evaluate the data associated with one, or multiple claims. Ultimately, these techniques can increase revenue for healthcare organizations and create efficient claims processes, helping both patients and providers.
Interactive reports allow providers to filter data for specific subsets of information. Filters can be broad or specific, retrieving data from regional, to single-payer denials. These analyses can identify claims denial trends, the leading step towards prevention. For example, if a revenue cycle director is panning through a facilities denial rate dashboard, they can easily access a list of denials associated with a single payer. By interactively supporting the viewer’s logic and information request, the interactive report reduces the complexities and high level of details involved in denial management.
Analytics dashboards are an excellent analytics tool and starting point for denial prevention. Because they primarily gather data, instead of immediately identifying root causes and implementing solutions, dashboards can show at a glance the losses and overarching areas for denial. Without a tool like this, providers would need to go through hundreds, perhaps thousands, of claims individually, which would be a time-consuming and labor-intensive process. With a broad “big picture” approach providers can view the overall claims denial rate, along with the first pass rate and clean claims rate. Dashboards illustrate the overarching themes and deficits of claims processing and are useful overviews before instituting strategies and solutions.
Claim-by-claim data compares denials from a side-by-side perspective, analyzing subtle differences between similar claims to understand what causes denials. The key to lowering denials through this approach is context. Small, specific nuances in claims can indicate drastic areas for improvement. For example, if the only difference between two claims is their department origin, and one was denied while the other was approved, it is likely that the staff insufficiently processed the denied claim and could benefit from reporting/submission training. Many defects in the claims process can be identified and improved in this way.
According to a recent survey, healthcare organizations have been slow to adopt data analytics and reporting solutions, despite the potential that they can improve the revenue cycle. 55% of facilities don’t have data analytics and reporting solutions in place. Without these analytics and reporting solutions, providers may not only be losing revenue but could also fail to provide the appropriate care necessary to their patients. However, 45% of organizations lacking analytics solutions are 45% actively looking for one, illustrating the value of accurate, timely reporting processes to the bottom line of providers nationwide.
As more healthcare organizations adopt data analytics, a competitive market will indirectly encourage other providers to do the same. Claims management will become more productive thanks to data analytics, and the healthcare industry will become more financially sound, in both small practices and large hospital settings. A financially stable healthcare industry can better serve not only professional staff but also patients, returning to the overarching goal of wellness and service.