Claims Denial Management Essay

Claims Denial Management Solutions claims denial management and related analytics solutions are showing big opportunities for hospital revenue cycle gains.
When it comes to improving the hospital revenue cycle, one bright area with emerging technology solutions is claims denial management with related analytics reporting. Two recent studies show how these solutions are helping to greatly improve cash flow and collection results, as the industry transitions to new goals and policies being set by CMS and related legislation.

"...the industry is essentially on the cusp of all providers needing a modern and effective way to handle denied claims in lockstep with the transition to value-based care and, to a lesser extent, the upcoming Oct. 1, 2106
date after which the Centers for Medicare and Medicaid Services is poised to demand greater specificity in claims submitted using ICD-10 codes." — from Healthcare Finance News article

While the industry is seeing emerging technology solutions, an HIMSS survey finds that a high percentage of hospitals still don't use the latest claims denial software. The HIMSS survey ("Essentials Brief: 2016 RCM Denial Management Study" from June 2016) observes that "more than half of hospital executives recently surveyed by HIMSS Analytics said their facilities currently don’t use vendor claims denials management software. However, that could change fast as providers face an urgent need to optimize revenue while moving toward value-based reimbursement models," observes Revenue Cycle Insights, after reviewing the recent HIMSS survey.

The HIMSS findings are further supported by other research.
Another survey from Navicure found that a majority of healthcare organizations using revenue cycle analytics solutions were able to improve key performance indicators, including claims submissions. According to the authors, "The majority of survey respondents were executives (42%), practice administrators (35%) and billing managers (22%). Respondents represented a broad range of specialties and sizes: 43 percent from organizations with one to 10 providers; 27 percent with 11 to 50 providers; 9 percent with 51 to 100 providers; and 21 percent with more than 100
providers."

The survey found that, "The majority (71%) of organizations noted these [data analytics] solutions have helped them achieve cash flow improvement through reducing days in A/R, followed by increasing revenue by identifying bottlenecks to get paid more quickly (56%). Almost half (48%) indicated staff productivity benefited from data analytics because it helped identify additional training needed."

The SSI Group, developers of the Revenue360 platform, also offers a robust and interactive analytics and denial management solution for claims processing, ideally suited to meet current industry needs.
And, the Revenue360 system includes a Claims status module that initiates a real-time claim status request during the claims follow-up process. Within seconds, claim status is verified and the user is notified with a customized response and suggested next steps based on the facility business rules, using automated intelligent guidance. This software is designed to address the challenges hospital financial teams face each day. A recent post by Hafid Mirza, a medical billing consultant, on LinkedIn listed the top 10 major sources of
denials:

Patient related, incorrect information denials
Provider related authorized or certified denials
Incorrect ICD
Incorrect Modifiers
Incorrect CPT/Units/Price
Duplicate claims
Missing Claim Information
Inappropriate Bundling
Incorrect POS
Authorization/Referrals
Sound familiar? RevCycle Intelligence boils this down to 4 medical billing issues with suggestions on how to overcome them in a recent article. According to the article, revenue cycle teams will do well to focus on:

Failure to capture patient information leads to claims reimbursement delays
Neglecting to inform patients about financial responsibility spells collection issues
Reducing the manual claims management processes
Inaccurate coding
As Healthcare Finance reports in this quote, "Leading up to the changeover to value-based care, healthcare organizations should focus on fine-tuning the process of claims denials," said Brendan FitzGerald, Research Director for Advisory Solutions at HIMSS Analytics. "There's opportunity for both vendors and hospitals to really dial-in these processes."

We continue to see the same opportunities for our hospital clients and look forward to continually bringing robust technology solutions for claims denial management and related analytics reporting.