Claim denials and delayed reimbursements are a fact of life for most if not all healthcare organizations. In a recent revenue cycle survey from Advisory Board, claim denials have increased substantially over the past six years posing a major threat to healthcare organizations.

Denial management works circularly with denial prevention. Analyzing your organization’s claim data and denial trends is the first step in putting processes in place to prevent future denials. How closely are you keeping an eye on your denial percentage rate? Do you know the primary reasons for claim denials that you’re facing?

Here are six tips to reduce denial rates from front to back. Keep in mind that clean claims are paid quickly, with minimal account touches to increase reimbursement by keeping resource cost low.

Obtain Accurate Patient Demographics

We sympathize. Your clinics are understaffed and your volume of patients is increasing. The priority is on the patient’s clinical care and the registration piece can be done anytime, right? Sometimes, as in emergent situations, it’s downright impossible to get any patient information, let alone accurate demographics. But for all the non-emergent visits, consider the importance of obtaining accurate registration information up front. According to the Ponemon Institute’s 2016 National Patient Misidentification Report30% of medical errors and 35% of all denied claims are the result of patient misidentification.

Have you established front end procedures on how and what information to ask the patient, and how to follow-up when it’s unattainable?

Some patients are unforthcoming with their personal information, and sometimes the patient representative doesn’t ask thoroughly for information that has changed since the patient’s last visit, or doesn’t record the their answers accurately. Demographic information, such as middle initials or addresses, are easily glossed over, but their absence can make a big impact later in the revenue cycle.

Verify Insurance Eligibility in Advance of the Patient Visit

Insurance eligibility is another crucial piece that is not being checked each and every time the patient comes for an appointment. Some organizations have policies flag the patient only once per year for a thorough registration. That may be convenient at the time of scheduling, but a lapsed or expired policy will create major inconveniences down the line.

Are you performing insurance verification for eligibility at each and every visit?

Use eligibility software to see if coverage is in effect for the current date of service, and also that the patient policy covers the procedure. In addition, verify if there is a need for pre-authorization in advance of the visit. If your patient representative is asking, “Is the insurance on file correct?” consider asking instead, “Do you still have [insurance plan]?” Patients are often unaware of changes to their plans until they receive a bill for a denied claim much later. That’s a real inconvenience for your patient who believed he or she was covered.

Obtain Pre-authorization and make sure it’s inclusive

Pre-authorization denials can be a headache on the front-end, partially due to a lack of standardization among payers. Developing processes and workflows by payer for the staff who need to submit the pre-authorization request is imperative.

Is there an administrative issue on the front end? Are key details of the medical record not being remitted? 

First, focus on a handful of the most common payers in your region and train staff on the details the payer requires during their pre-authorization process. The biggest challenge is balancing patient expectations with payer expectations. If a patient believes they should be covered for a service, but their payer declines authorization due to something in the medical record, the burden of educating the patient about their financial responsibility falls to the provider.

Second, check the number and frequency of claims denied for missing prior authorizations and identify where the errors are originating, and which payers frequently deny.

Payers need specific information to approve authorization, and they will ask for it in a particular format. If the information is present and correct but not easily accessible because too much additional information was also submitted, they may deny.

Ensure claims are filed with the payer in a timely manner

There are several reasons that a claim may not get filed in a timely manner, and there are even more reasons to make a diligent effort to get those claims in on time. Government payers are generous with their timelines, but some payers only allow a short window to file, and even less time to follow up if there’s a denial or issue.

Do you know the timely filing guidelines for your major payers? Are aged claims being deprioritized for follow-up, causing missed filing windows?

Like the slogan says, “You can’t win if you don’t play,” you’re guaranteed to lose revenue if you don’t submit a claim timely. If this is a recurring issue within your organization, segment follow up work queues by age of claim and payer. Work the oldest claims first as part of your ongoing work strategy; this will minimize delayed reimbursements and ensure you do not miss out on revenue altogether.

Verify that charges are correct and appropriate for the services provided

Use correct codes and modifiers to ensure accurate and clean claims submissions. A detail-oriented and thorough coder will individually check and code each unique claim. And yes, 73,000 codes (and counting) in ICD-10 pretty much guarantees that each diagnosis corresponds with a specific code.

If you have a physician practice, are you currently HCC coding? Are your coders pursuing ongoing education?HCC (Hierarchical Condition Category) coding is one of the easiest ways to substantially increase specificity in coding by reporting the true cost of care on your particular patient demographic. Another way is ensuring your coders are up-to-date on best practices and regularly participating in education to ensure the correct codes and modifiers are used for every claim, every time.

Appeal denied claims and send corrected claims in order to increase payments

According to the recent revenue cycle survey from Advisory Board, there is a downward trend showing that denial appeals are less successful than ever before. On average, only 45% of appeals are successful with private payers, and only 41% are successful for Medicaid appeals. The good news is that Medicare and Medicare Advantage appeal success rates have actually increased over the past two years from 50% to 64%.

Do you currently appeal all denied claims? Is the cost to collect worth the effort?Those might sound like obvious questions, but many organizations never bother with appeals due to the high cost to collect. The process of appeals is cumbersome (printing medical records, filling out corrected claim forms, mailing by snail mail, etc.) so it really might not be worth appealing low-dollar claims, but you won’t know until you complete the legwork. Segment denial work queues by high dollar accounts and devise a work strategy for staff to send appeals on a pocket of claims with a similar denial code to increase efficiency in the process of collecting.

The Bottom Line

We wish you 100% clean claims 100% of the time — (accurate, specific coding, full coverage insurance, no payer denials or hang-ups) but our industry has become more complex and with that comes difficulty in getting a high claim reimbursement percentage outright. Creating a purposeful and diligent effort on the front end by following the six tips above can help reduce manual claim follow-up efforts, redundancy in work, and decrease delayed insurance payments down the line. And all that translates to more revenue for the care you provide.