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Four Opportunities to Reduce Denials and Get Paid Faster

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If it seems like you’re experiencing an increase in payer denials, you’re not mistaken. Payers are now using sophisticated algorithms to more easily identify things like potential DRG downgrades and issues with medical necessity.[1] Payers are also using more complex claims submission criteria, often including requirements that go well beyond those of the CMS.[2] And, of course, these requirements all vary payer to payer, which makes staying on top of them challenging, especially for organizations experiencing staffing shortages.

All of this results in more work for providers on the back end, trying to recover much-needed revenue. For many organizations, this means focusing only on the highest-dollar balances and ignoring the smaller balances. Research shows that up to 65% of denied claims are never reworked.[3] Those smaller balances, however, can add up over time.

The good news is that 90% of denied claims are avoidable.[4] What can providers do to protect their bottom line against denials? The first action is to understand where denials come from so you can take proactive steps to prevent them.

According to one study, “out of $3 trillion in total claims submitted by healthcare organizations, $262 billion were denied, translating to nearly $5 million in denials, on average, per provider.”[5]

The top reasons why claims are denied[6] include:

  • 23% – Issues in registration or eligibility
  • 14.6% – Missing or invalid claims date
  • 12.4% – Authorization & precertification issues
  • 10.8% – Medical documentation requested
  • 10.1% – Service not covered
  • 5.8% – Problems with medical coding and medical necessity
  • 3.5% – Missing timely filing deadline

Since the majority of denials begin in the patient access process, this is where you should focus your efforts.

Streamline eligibility and benefits verification

Since nearly a quarter of all denials can stem from eligibility issues, it makes sense to do all you can to streamline this process. The best way to do this is through a hybrid approach, one that combines technology with the more manual processes. For instance, technology, including APIs and BOTs, can automate eligibility verifications. It can be set to run batch eligibility requests overnight or on a specific schedule so that providers have the information they need prior to patients arriving for their service.

While technology goes a long way in streamlining the process, more manual activities shouldn’t be overlooked. This should include a variety of eligibility and benefits verification methods, including phone, payer portals, email, and fax. In other words, no stone should be left unturned. This is especially important for secondary and tertiary payers, which can be more complex to work with.

Pay special attention to prior authorizations

Prior authorizations are challenging. In a survey by the American Medical Association nearly 68% of providers said it is hard to determine if a prescription medication needs prior authorization, and 58% said the same challenge for medical services.[7] Prior authorizations also take a lot of time. It can be exhausting for staff, as well as for patients who are waiting for payer approval so they can receive their service. When proper authorization isn’t attained prior to service, the claim is likely to be denied, leaving patients with a hefty bill they’re unprepared to pay. This can negatively impact the patient-provider relationship, reduce patient satisfaction ratings, and ultimately end up in a write-off.

87% of physicians surveyed said prior authorizations interfere with continuity of care.[8]

It can be helpful to assign specific staff to stay on top of payer requirements in order to understand each payer’s prior authorization requirements and payer-specific rules. The right team members should have advanced knowledge of payer requirements. If you have enough staff, you can assign specific payers to specific staff members to make it easier to stay on top of changing requirements. 

Rethink denials management

When denials do happen, automated workflow tools can streamline the entire process. By linking the denial to the original claim, these tools can identify root causes without time-consuming manual research. You’ll be able to identify problematic trends so they can be proactively addressed to reduce future denials. If your organization has a denials technology platform, you can create work queues and assign them to specific staff and manage the appeal process for each payer.

Consider outsourcing

Preventing denials requires a comprehensive strategy that includes both technology and manual processes. For organizations that lack the technology or the expertise needed to effectively identify and address the root cause of denials, or for those struggling with staffing shortages, outsourcing or augmenting their patient access or denial management needs can be a great option.

Omega Healthcare is a great choice as a partner. Our technology-enabled services, along with our team of revenue cycle experts, allows us to manage more than 3,000 claim status retrievals per hour. On average, our clients experience a 25% reduction in denial turn-around-times. Following is an overview of our comprehensive services and solutions that help reduce denials and lost revenue.

Eligibility & benefits verification

  • Identify unknown patient insurance coverage, including tertiary and secondary coverage, prior to the patient visit or at time of registration via electronic or manual processes, including phone, payer portals, emails, and fax
  • Contact patients pre-service to gather any missing insurance or demographic information
  • Leverage secure technology, including BOTs and APIs, to streamline status checks for faster processing of large inventories
  • Create patient responsibility estimations
  • Follow up on outstanding encounters that haven’t been cleared
  • Provide data insights and reporting on verification workflows

Referrals and prior authorizations

  • More than 400 prior authorization experts review every patient chart prior to service to identify prior authorization and medical necessity documentation requirements
  • Authorization types include imaging orders, inpatient and outpatient surgery, medical procedures, prescription drugs, and physical and occupational therapy referral.
  • Provide authorizations for both primary care physicians and specialists
  • Call providers to verify authorization when required by the payer
  • Manage referral requirements and route requests of high-value complex specialties

Denials management

  • Re-status and rework denials through payer portals and phone calls
  • Work closely with the provider and internal teams to address concerns such as credentialing issues, incorrect denials, and underpayments
  • Track recurring, high-impact denials to proactively identify and correct issues
  • Understand national and local coverage determinations and regulatory guidelines
  • Work with the provider to modify workflows and systems to ensure compliance with payer updates and regulatory changes

Appeals

  • Work with both providers and payers for more successful appeals
  • Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials
  • Leverage industry guidelines, best practices, and national and local coverage determinations to review records and create appeals
  • Create and maintain timely filing limit matrix for resubmission and appeals to ensure timely appeals and resolution
  • Follow up until denial is accepted or rejected to close the loop

Tech-enabled services

  • Automate medical documentation workflows to streamline research and connect medical records to the denial for faster resolution
  • Create itemized statements, pulling information from the provider’s system to upload to a payer’s website
  • Provide edits, workflow modifications, and systems cleansing to ensure the provider’s claims submissions align with payer compliance changes and regulatory updates

Reporting and analytics

  • Conduct systemic root-cause analysis to identify and address upstream process issues to prevent future denials and potential write-offs
  • Analyze payer adjustment codes from remittance advice, including case management and utilization review
  • Provide denials analytics based on the provider’s preferred cadence: daily, weekly, monthly

The bottom line

It is estimated that hospitals could lose up to $54 billion in net income because of the COVID-19 pandemic.[9] They simply cannot afford to be complacent with denials. Partnering with Omega Healthcare for all or a portion of your denial management needs can bring even greater benefits by streamlining workflows, reducing write-offs and helping providers get paid faster and in full.


[1] “Why your denials are skyrocketing (and 3 ways hospitals can respond),” Eric Fontana, Managing Director and Robin Brand, Senior Director, Advisory Board, published in Modern Healthcare, March 13, 2019

[2] Ibid.

[3] “Success in Proactive Denials Management and Prevention,” Glen Reiner, HFMA, May 18, 2021

[4] Ibid.

[5] Ibid.

[6] “Don’t just manage payer denials, prevent them,” Phil Goyeau, 3M, Presented at Connecticut Health Information Management, December 13, 2018

[7] “2020 Update: Measuring progress in improving prior authorization,” American Medical Association, May 2021

[8] Ibid.

[9]“Financial Effects of COVID-19: Hospital Outlook for the Remainder of 2021,” KaufmanHall as published by the American Hospital Association, September 2021

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