By Kristen E. Hughes, Senior Client Services Manager, MediRevv
The UnacceptableTruth About DenialsBy Kristen E. Hughes, Senior Client Services Manager, MediRevv
Instead of counting sheep, are you counting the lost dollars and too
many days in A/R that threaten the health of your revenue cycle?
IF YOU’RE NOT, YOU SHOULD BE.
Are you seeing the word “denials” inyour sleep these days?
CAN you afford that?
DID YOU KNOW?$25 x 100 claims = $2,500Average cost
of rework
Average number of claims that
require rework per monthAverage cost per monthto work unclean claims
Source: MGMA Connection, February 2014
ALSO...Only about 2/3 of denials are recoverable
BUT 90% of themare preventable
Source: At the Margins, Advisory Board Company, December 11 2014
There was a time when you sent claims out to payers andconfidently expected full reimbursement for your services.
Maybe even an annual reimbursement rate increase to boot.
THOSE DAYSARE GONE!
Not only are Medicare payments projected to remain flat forthe foreseeable future, navigating through increasingly
complex reimbursement requirements has becomeultimately challenging.
With changing reimbursement
rules and complications
associated with ICD-10, it’s
imperative that provider
organizations do everything
they can to capture 100% of
revenue owed to them by the
insurance companies.
That’s why a solid DenialsManagement Strategy is
absolutely vital.
Here are a couple reasons…
Understanding why denials happen is a
good first step in developing your strategy.
Registration issues
Getting things like patientidentification, patient
insurance eligibility and validinsurance coverage right atthe outset is the beginning
of sucessful denialsprevention
Coding challenges
Claims with incorrect, incomplete, or missing codes are denied.
The best way to reduce coding-related denials is to make sure
your claims are clean right out of the gate.
It’s absolutely vital to have the right, highly trained coders on
staff, and a quality assurance (QA) auditor is icing on the cake.
The physician credentialingprocess can be an arduous, slow
process, usually entailingconsiderable paperwork and
extensive review of theclinician’s accreditation. The
process may have to berepeated when the
credentialing expires, oftencausing a denial.
Credentialing considerations
Denials increase when you don’t have a well-conceived process
in place that ensures your admission precertifications and
procedure authorizations are consistently handled
appropriately and don’t fall through the cracks.
Precertification problems
Those are just some of the many reasons denials happen.
Here are several more:
Charge Entry
Referrals & Pre-authorizations
Info from Patient
Duplicates
Medical Necessity
Documentation
Bundled/Non-covered
Obviously, your game plan
should include both
eliminating denials to the
greatest degree possible by
submitting clean claims
initially, and also reacting
quickly and correctly when
denials do occur.
Yet for a strategy to succeed you’ll need
considerable expertise and significant resources.
For many providers, thispresents a challenge.
In an environment where
many healthcare
organizations are already
feeling the budgetary pinch
and resource challenges,
how, you may be wondering,
can you accomplish all this?
One great way is tooutsource some or all of
these business officefunctions, but it’s important
to find a firm with thecharacter, integrity,
expertise and proven trackrecord of results.