For healthcare providers, maximizing revenue potential necessitates efficient insurance claims denial prevention strategies, and protocol. Managing and resolving claim denials is an essential responsibility of your revenue cycle team. However, the prevention of claim denials requires participation from physicians and administrators alike.

Substandard denials management leads to financial pitfalls for any practice. Revenue cycle delays and losses due to denials are costly in multiple ways including increased staff work, and decreased productivity. Many clinical and technical denials can be prevented with a robust denial prevention program. Expected denials that are unavoidable need to be managed effectively. A comprehensive revenue cycle program includes a denials strategy that focuses on front-end processes and the variations in payer contracts. When denial management strategies work, financial returns are maximized.

Successful revenue cycles depend on denial management:

The increasing complexity of healthcare payment systems has increased the importance of denial management in ensuring healthcare providers’ fiscal stability. Denials affect revenue, increase paperwork, and hinder collection efforts. By adopting best practices for denial management, providers can recover lost income, decrease the frequency of denials, and improve overall operations. In 2021, claims denials increased by nearly 20%, according to a poll conducted by the Medical Group Management Association (MGMA), amounting to approximate 50 million claim denials. Payers have reported denial rates as shockingly high as 80%. When properly appealed, 40% of these denials can generally be overturned.

Denied claims certainly impact a practice’s cash flow, but also increase administrative costs due to the need for the rework and resubmission of claims. The delay in reimbursement caused by these denied claims can increase accounts receivables, and further strains a practice’s revenue cycle management.

Taking preventative action by submitting error-free claims is critical for healthcare providers when working to transform their revenue cycle. Earnings are maximized since reimbursements are more likely to be received on time, and the work required to resolve and resubmit denied claims is reduced, while cash flow is increased.
Developing a concise denied claims resolution process will increase a practice’s cash flow. Healthcare providers can then invest more time into patient care and improved infrastructure, while meeting their financial obligations.

Simplified operations reduce errors:

Denial management strategies that identify common revenue cycle process faults are a must. Analysis of these denial patterns help practices resolve recurring issues including frequent coding errors, inaccurate paperwork, and billing issues. When operational glitches are isolated and corrected, denial rates drop.

Enhancing relationships with payers is imperative to increasing approval rates. Using a cooperative approach reduces conflict and speeds up claims processing.

Maintaining open lines of communication and solid connections avoids confusion regarding payer requirements, and addresses difficulties quickly to avoid denials.

Operational efficiently and noncompliance policies:

Fines, audits, and potential litigation are all mitigated by effective denial management. By regularly educating employees about changes in payer policies and rules, providers can additionally avoid regulatory noncompliance issues.

Process simplification improves denial management efficiency. It is often possible to reduce administrative intervention by streamlining and removing obstacles. By automating denial monitoring, prioritizing high-value denials, and utilizing technological solutions, providers can optimize revenue cycle processes. By focusing on vital duties such as denial prevention, appeals, and patient involvement, operational efficiency is enhanced.

Streamline the front-end process

Although claim denials will continue to be common, the front-end of healthcare may be the most important staging ground for successful denial management. Denials are caused by front-end issues in 41% of cases. Registration and eligibility errors contribute significantly to denials of which 55% are not recoverable, but avoidable.
Typical catalysts for denials are coding errors, insufficient paperwork, lack of prior authorization, and inaccurate invoicing. By analyzing a practice’s trends and patterns, providers can identify their most common reasons for denial and take corrective measures. A provider’s success in reducing denials can be improved through efficient, effective front-end processes, including collecting accurate complete patient data, verifying insurance coverage, and obtaining necessary patient permissions.

Simplify coding and proactive claim scrubbing:

Prior to submitting claims, it is important to proactively scrub for denial triggers. Performing automated checks on claims before submission is becoming standard for providers using sophisticated claim scrubber tools or revenue cycle management software.

Accurate credentialing is necessary for physicians and facilities. Avoiding the filing of unauthorized services and ensuring the maximum benefits for the patient have not been exceeded is crucial. Always identify the correct location of the service performed and correct any missing or incorrect modifiers for the procedure code.
Incorrect coding or data, such as mismatched totals or mutually exclusive codes, improperly bundled services, and missing the claim filing deadline must be addressed first. Health care organizations should ensure continuing education and training for coding employees is in place to boost precision and reduce invalid claims.
Appeals and follow-ups:

Approximately 60% of denied claims are never resubmitted. Recovery of this lost revenue requires a simplified appeal process and follow-up procedures. Appealing denials is less time consuming with effective protocols and technology in place to automate tracking and monitoring. Periodically reviewing denial data and evaluating critical metrics is key for identifying patterns, trends, and areas for improvement. By using analytics and reporting systems, users can learn about their denial rates, reasons, payer trends, and performance standards. Monitor feedback from payors and maintain open lines of communication regarding changes in denial policies. Clarify and correct common coding and any commonplace documentation issues to reduce the chances of repeat denials.

Accelerate cash flow

Cash flow, revenue, and patient experience are negatively impacted by denials.
Virtual OfficeWare Healthcare Solutions (VOWHS) knows that denial management improves performance in healthcare organizations. Providers can increase their financial security and improve their revenue cycle by applying proven denial management techniques.

The bottom line of your medical group is almost always adversely affected by excessive claim denials, but relying solely on your internal team may not always be the best choice. Most staff are already overburdened due to limited resources and time constraints. Coding volume increases and regulatory changes happening each year can be overwhelming, and many groups lack the appropriate level of technology infrastructure and automation support to customize workflows that prevent denials. Complex billing and coding requirements can lead to errors and oversights and lack of expertise makes it difficult for practices to uncover all the factors contributing to claim denials. When it comes to reducing or preventing denied claims, collaborating with an expert with deep industry experience can result in substantial financial benefits.
Providers can succeed financially if they take a proactive and modern approach to the healthcare market. Data analytics and technology solutions can help providers stay competitive in modern healthcare.

VOWHS has the specialized experience and advanced proprietary medical billing software athenaCollector®, to catch claims errors before they are submitted. Our team of experts is up to date with changing regulations and payer policies, ensuring accurate billing and coding.

With proven denial management strategies, physician practices can improve cash flow, reduce administrative costs, and improve their bottom line. Claims denials don’t have to be a significant cost of doing business. It is possible for healthcare providers to reduce denials, improve reimbursement rates, and achieve financial success by conducting root cause analysis, optimizing front-end processes, coding, and documentation, scrubbing claims, streamlining appeals and follow-ups, monitoring denial data, and communicating with payers.

Need better control over your claims cycle and denial management? We’d be happy to assist you, contact us.