While healthcare reform has received a lot of attention in American policy in recent years, the healthcare industry continues to face challenges. Healthcare providers give top priority to patient care, but they must also collect payment for their services. However, providers often struggle to receive full and timely payment, even with increasing numbers of insured patients, new payment models, and new medical technology. Contributing to the pressing financial problems that healthcare providers face is the denial of insurance claims, which can cost an estimated 3 percent of a provider’s revenue. The problem stems from several factors that occur as a claim is processed, so there’s no single fix to solve the entire problem. With everything from patients delaying or avoiding payment, to mistakes made by personnel when filling out insurance claims, there are numerous opportunities for a claim become denied. However, it is vital for hospitals to tailor various strategies and solutions that will increase operational efficiencies, awareness, and ultimately prevent denials on the front and back-end.
Over half of denied claims are not resubmitted by healthcare providers. Many providers have struggled to fund and staff the appeals process for denied claims, and need guidance on implementing a sustainable prevention system for denials. Frequently, problems earlier in the claim submission process lead to the denials of claims, which means that if providers apply effort early on, they will encounter fewer denials later.
To address denial prevention, providers would benefit from determining specific information about their denials, including denial, claims, and dollars rates. This information can inform the best place to start on denial prevention, as well as identify possible trends in denials. In addition, providers must determine which claims to appeal, and how many.
Healthcare professionals need an environment where they won’t fear backlash if their department needs to change their conduct. As people are an integral element in the issuance of denials, sensitivity and collaboration can reduce resistance to denial prevention, and increase the cooperation of employees.
One way to utilize employees more efficiently is to group everyone who works on denials into one department. Structuring denial response in this manner can enhance communication between employees, and identify potential issues sooner. To address denial response processes, providers can group denials together by type. By sorting denials by type, providers can spend time on sources of denial besides payer-specific ones, and streamline the denial response process. Moreover, providers must accurately assess their progress in their denial prevention strategy. The number of appealed claims does not necessarily indicate recovered revenue. Instead, providers should approach denials with the mindset of correcting a trend in denials, or making changes that will yield the greatest benefits.
Extra attention can be paid by healthcare providers to verify that a claim adheres to payer-specific and regulatory requirements. Yet another way to minimize denials is to catch coding errors before submitting the claim. When a claim must be corrected after a denial, it costs providers time and money as their staff spends time fixing mistakes instead of filing new claims. Maintaining awareness of claim deadlines, and even setting automatic reminders, can help avoid more claim denials.
Real-time analytics can identify areas that may be prone to costly errors. These areas may include data entry, patient pre-authorization, coding, claim editing, and appropriate clinical documentation. A common set of issues contribute to claim denials. Some lead to delays in gaining payment, such as an insurance company requesting more information about a claim. Other billing problems could lead to an outright claim rejection, which could happen by submitting claims for a treatment that isn’t covered by the patient’s insurance. Therefore, analyzing the technology, people, and processes involved in submitting a claim may help reduce the risk of receiving a denial.
Healthcare providers can also update their analytics technology to enhance their denial response strategy. Using an analytical system that can map the denial for review and categorization will help providers gain access to valuable data about their denials, and arm them with the information they need to address similar instances in the future.
The vast majority of claim denials can be prevented if providers know the causes and locations of their problems. One crucial part of preventing denials is to verify that a patient has coverage and that the provider has collected the patient data it needs to submit a claim. It is not feasible to continue sorting out billing and patient information after the treatments have occurred. A better approach to billing is to obtain accurate patient information upon interacting with a patient, and pre-registering them with the provider before receiving treatment. If a patient plans to pay for their treatment without insurance, the provider can determine whether the patient has Medicare or Medicaid coverage. Preventing denials can also be achieved through pre-authorizing treatments and ensuring they are considered medically necessary. Insurance companies regularly reject claims on the basis of lacking medical necessity, which is avoidable.
Equipping your facility and integrating the right platform across departments is vital to controlling and preventing denials. For effective billing infrastructure and a team dedicated to following and appealing denied claims, look no further than eReceivables. Our patented automated appeals system allows us to address both high balance claims, and lower claims that are often overlooked and leave valuable funds uncollected. Every claim will be pursued.