Denial Management To Denial Prevention

A number of healthcare institutions tend to lose out on a chunk of their revenue due to denied claims. An estimation was made where it was seen that the claims that have been denied by the insurance companies do not get resubmitted by the hospitals.

The claims that do get denied are mostly because of the errors committed by the staff which can be easily averted when proper adherence is maintained for policies. The management of claim denials requires a lot of time, effort, and money. In order for a medical institution to focus on denial prevention, it is crucial that they have well-trained staff. 

How Does Effective Management Help With The Prevention Of Claim Denials?

There is a saying by a Dutch philosopher which says “prevention is better than a cure”. If you were to apply this in the medical world, you can gain a lot of perspective on a number of things. When it comes to claim denials, one can easily prevent a claim from getting denied when there are no errors made.

An efficacious denial prevention program needs sequential procedures which include the recognition of the causation and finding the proper solution for it. This way errors can be easily prevented from occurring in the near future. When these procedures are kept up to date and the staff is well-trained claim denials remain almost zero.

Outsource revenue cycle management and coding services

Steps To the Prevention Of Claim Denials

There are a number of steps that must be followed in order to prevent claim denials.

1. Understanding the enormity of the difficulty

An effective denial prevention program is one that helps in enabling a substructure that can lead to the reduction of claim denials. In order for this structure to exist and function in a proper and efficient manner, one must understand the gravity of the situation. There are three ways that can help you determine the immensity of the situation.

I. Percentage of the high-value claims which was denied as a percentage of the total claim denials.

II. Denial rate

III. Percentage of appealed claims.

2. Classifying the root problems

Understanding and categorizing the causations of the denied claims helps in understanding the issue in a simpler manner. Making sure that a proficient team looks through the necessary data from time to time will help with the identification of the root causes hence finding a solution for each of them. The majority of the denied claims can be avoided quite easily by the medical billing companies.

3. Major causes for the denials of claims

There are a number of reasons which can lead to denied claims.

I. Incorrect or insufficient information

II. Not filing the issues on time

III. Prior authorization

IV. Incorrect use of codes

V. Duplicate claims

VI. No proper credentials given to physicians

4. Calculating the favorable outcome which can result from the denial management program

When the success is calculated for the denial prevention program, the key is to make sure to calculate the appeals that have been submitted successfully along with the general minimization of the denial rates. Even when resubmission of claims is a short-term goal, the end game of it all remains in achieving a substantial alteration of the denial rates.

When it comes to denial management in healthcare, the overall revenue of the hospital increases with the denial management program being strong and efficient. It also helps in shifting focus to the prevention of denials. There are some key elements when it comes to denial prevention programs which are as follows:

  • Using analytics to help with the identification of the root cause
  • Recognizing the errors that can be prevented in the majority of the denials makes the process easier. Most of the claim denials occur due to inefficiency in coding and billing procedures, authorization, and eligibility issues.
  • Taking constant details and resources from a variety of payers in order to keep the procedures up-to-date.
  • Creating a team of proficient individuals in order to address the denials and help in making necessary changes which can lead to the prevention of these claim denials. 

The amount of revenue that is lost by the hospitals and medical practitioners due to inefficiency in medical billing is a lot. It is crucial that hospitals hire proper medical billing companies instead of relying on their in-house staff when medical billing and coding are concerned to avoid claim denials.

When a medical organization decides to outsource revenue cycle management and coding services it helps in the reduction of errors and claim denials. They work efficiently right from the beginning of the procedure until the amount is reimbursed by the insurance companies.

How Are Digital Innovations Boosting Revenue Cycle Management These Days?

denial prevention program

With the acceleration of technology and everything becoming digitalized day after day, it should not come as a surprise that digital innovations are now providing a boost to Revenue Cycle processes these days. The process of digital renaissance is now occurring during an unforeseen time which is only leading to the positive growth of RCM. 

With medical practitioners and patients increasing in number on a regular basis, the management of a healthcare institution nowadays has to be more systematic than ever. At the end of the day, in order for a healthcare service to continue its business, it is important that it manages its revenue successfully. The revenue cycle processes were designed in a manner that would help uncomplicate the financial side of the medical institutions. 

With newer digital innovations coming into the market, it has become much easier to file claims. Artificial Intelligence (AI) and bots have been taking over the world of healthcare and the entirety of RCM. There have been quite a few significant conveniences that have occurred due to these changes as well. 

These machines have been quite efficient in learning the new changes as they occur on a daily basis. They also help the team in making dynamic decisions regarding the reimbursement systems along with the healthcare records. For instance, AI is capable of spotting denial issues which helps the RCM teams in responding to them faster. This, therefore, allows these professionals to achieve a proper and efficient workflow overall. 

In case you are looking for a reliable and experienced service provider of RCM, Synergy HCLS can be an excellent choice for you, considering their flawless track record. They have gained deep expertise in the field of revenue cycle management.