Why Claim Denials Management is All about Process

Claim denials happen to everyone. In reality, it is usually payers who ensure that they are unavoidable. When it comes to working those denials, though, there is no space for complacency.
When a claim is mistakenly paid or refused, there are two options. First, if no further action is taken, the amount owing to you will go uncollected, reducing your revenue. Second, when action is taken—when the underpayment problem is uncovered or the refused claim is addressed and correctly resubmitted—payment is made, but you suffer fees along the route. The expenses of those denials accumulate over time and have an impact on your bottom line.

While there are a variety of reasons why a claim may be denied,  proven denial management solutions in place are critical for maximizing payouts and minimizing expenses. Many healthcare institutions lack the necessary technologies to prioritize and route denials to the appropriate claims specialists. Often, firms are just not built up to handle denials in the most efficient and cost-effective manner. As a result, claims expert teams work and rewrite claims, yet receive little or no payment for high-dollar treatment.

Everything revolves around the process. We’ve reduced claim denials management to two essential components for an efficient, best-practice process: technology and team structure.

Built Claim Denials Management based on technology

Don’t bother printing. Don’t use highlighters. Please do not dial. Don’t try to handle rejections using outdated or non-existent technology. Instead, ensure that your billing system and any claims filing tools are tail to accomplish the most critical stages. These include work assignments, effective follow-up management, quality tracking, and optimizing meaningful production.
However, existing technology falls short for many healthcare companies. For example, an institution’s claims filing program may have an easy-to-use interface, but the software’s underlying programming logic may be deficient. The present solution is insufficient and so ineffective without all of the required components.

Consider the following criteria. Your collective denials management toolkit should enable you to:

•  Organize and prioritize claims follow-up efforts across all payers.
•  Real-time productivity tracking results in goal-based incentives for team members
•  Respond fast (in minutes!) without having to manage a claims list yourself.
•  Carry out root cause denial trends and thorough reporting
•  Import patient accounting notes and activities into the host patient accounting system
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You are not alone if your organization’s billing systems and tools do not perform all of these. Several patient accounting systems only match part of these criteria, so start there and make sure you’re making the most of the technology and resources you already have. Furthermore, you may discover that a seasoned partner with these characteristics will best fill the void in your search for an efficient rejections claims management system.

Specialized Teams Resolve Denied Claims More Quickly

Once the core technology and tools are in place, the second phase of the process involves rearranging teams for efficiency. While each hospital and clinic is unique. The following approaches have been effectively applied in various healthcare institutions to improve denial resolution:

•  Organize your teams by the payer. The more claims experts are acquainted with their payer, the faster and more correctly they will work. Simply, specialist teams handle more claims, and more claims equal more income. Do this for both commercial payers and Medicare and Medicaid
•  Identify specialists from surrounding departments (for example, patient access and coding) to work claims that have been refused for grounds related to those departments. Maintaining strong communication channels across teams can expedite denials work.
• Use your technology from above to drive targeted and stratified rejections to these payers- and department-based teams. The procedure is straightforward: follow up, document, and move on to the next claim.
• Encourage teams to identify and report any possible patterns or problems.
• Create project KPIs with help of the best medical billing companies, communicate them with your teams, set suitable team and individual goals, and then measure them using your technology.

Having the correct technologies in place and creating a better team structure will enhance your claim resolution and income. If you’d like to learn more, please contact us and we’ll show you what the correct denials management process can achieve for your business.

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