Managing Denials in a Value-Based Reimbursement World

Medical Claim Denials
September 19, 2017

Posted by MedbillingExperts / 0 Comment

Claim denials are stuck in health organizations’ craw that has been eating into their net revenues at an alarming rate. Even though the switch from manual to electronic documentation is underway, the denial rate continues to hurt these organizations. What’s worse? The situation doesn’t appear to be improving anytime soon either.

The transition from fee-for-service to value-based care is expected to make billing trickier and complicate things even more, despite the use of advanced technology. Needless to say, these complex value-based payments will cause more denials and lead to revenue leakage, the very thing that the healthcare businesses have been trying to control.

However, does that mean these healthcare organizations are doomed? Clearly not! Here are the top three things you can do to manage your claims procedure and abate denials.

Evolve with Changing Times

One of the leading reasons why many organizations fail to straighten their denials management process is due to improper measurement metrics. Most companies still use traditional net denials as the key performance indicator while assessing denials. This metric tackles all denials as claims that are refused by the payer and needs to be written off.

For the organizations to manage and understand their claims’ process, they need to move away from the conventional “net denials” approach and adopt a model that takes evolving trend analysis into consideration. Through this analysis, the accounts can be identified where the primary payer details have changed after the billing date; segregation can be done based on service areas such as specialty units, ambulatory clinics, inpatient and outpatient; payer segregation based on comments, payment delays can be segmented as per priority and reason, etc. Evaluating the denial trends will provide a much broader view of mismanagement in the process and the areas that need fixing.

Take Corrective Action

Once you have analyzed the trends, the next step is to take corrective measures and improve the anomalies in the system. This is an all-inclusive process that involves reviewing three main components of your claims management – technology, process and people.

The technological advancement has made industries attain an all new level of efficiency. This can also be the case for healthcare industry if you use progressive healthcare software that allow real-time assessment of patients and conducts eligibility analysis on-the-spot. Use data to identify payment delays and map this information to recognize most common reasons for delay in payment. Even though this functionality exists in most healthcare systems, it is often underused and snubbed by employees at the backend. Before you invest heavily on off-the-shelf turnkey solutions, explore the available options.

Scaling up technology alone will not make the cut. You need to review your inbuilt processes to unearth inaccuracies and redundancies that are non-value addition time consuming tasks. To eliminate errors that lead to denial, you need to develop an exhaustive visit management process that includes all the steps from screening to collecting insurance related information and more. Quality of these processes should be monitored in all the aspects where there is a possibility of technical or manual errors.

The last most important element of claims management process is its people. Training and educating staff can have a huge impact on effectiveness of the process. It is important to eliminate the blame shifting game from the claims course and recognize improvement areas for a tighter and more efficient system.

Keep Strict Control on Claims Management Process

This is the most important step in minimizing claim denials. Setting up proper checkpoints and periodic review of performance metrics can go a long way in keeping the process simple and smooth. Regular audits are another way of reinforcing quality into your system. You can also consider incentivizing the claims management program to get everyone in the organization on same page. The people working closely at the backend may have the best idea about solving the denials problem. This is why you need all the stakeholders onboard and never underestimate the importance of experience in improving the processes.

Did you know that nine out of ten denials can be prevented? Analyzing the root cause of the problem and integrating appropriate procedures in your claim management process can take inefficiencies out of the system and make it profitable. With value-based-services just round the corner, it is important to fix the system while there is still time.

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