Why Insurance Denials Management is All About Process
Insurance claim denials happen to the best of us. In fact, it’s often payers that make sure they are inevitable. But, there’s no room for complacency when it comes to working those denials.
When a claim is paid incorrectly or denied, there are two possible next steps. First, when no further action is taken, the payment that is owed to you goes uncollected and your revenue takes a hit. Second, when action is taken––when the underpayment error is discovered or the denied claim is worked and re-submitted correctly––then payment occurs, but you incur costs along the way. The costs of those denials add up over time, impacting your bottom line.
While there are several reasons why a claim might be denied, having a proven denials process in place is essential to maximizing payments and minimizing costs. Many healthcare organizations lack the technology needed to prioritize and channel denials to the right claims specialists.
Often organizations just aren’t “set up” to work denials in the most efficient, least costly way. The unfortunate result is that claims specialist teams work and rework claims, but end up with little or no payment on high-dollar care.
Please know…it doesn’t have to be this way.
Process is everything. We’ve broken insurance claim denials management down to two fundamental components required for an effective, best-practice process: technology and team structure.
Technology Forms the Foundation of Denials Management
Don’t print. Don’t highlight. Don’t dial. Don’t try to manage denials with limited or no technology. Instead, be sure that the billing system and any claims submission tools you use are optimized to perform the most important steps. These include assigning tasks, managing effective follow-ups, tracking quality and maximizing meaningful productivity.
But, for many healthcare organizations, the available technology falls short. For example, an institution’s claims submission program might have an easy-to-use interface, but the underlying programming logic of the software might be lacking. Without all the necessary pieces, the existing solution is incomplete and therefore not fully effective.
Consider the following criteria. Your collective denials management toolset should allow you to:
- Prioritize and stratify claims follow-up activity across all payers
- Track productivity in real-time, resulting in goal-based motivation for team members
- Respond quickly (in minutes!) without self-managing a claims list
- Perform root cause denial trending and robust reporting
- Export notes and activity into the host patient accounting system
If your organization’s billing systems and tools don’t do all of this, you aren’t alone. Several patient accounting systems meet only some of these criteria, so start there and be sure you are fully using the technology and tools you have already. Beyond that, you may find that a proven partner with these capabilities will best fill the gap in your quest for an effective denials claims management solution.
Specialized Teams Resolve Denied Insurance Claims Faster
Once the underlying technology and tools are in place, restructuring teams for efficiency marks the second half of the process. While every hospital and clinic is different, these practices have been implemented successfully in countless healthcare organizations for boosting denials resolution:
- Structure your teams by payer. The more familiar claims specialists are with “their” payer, the faster and more accurately they will work. Simply put, specialized teams touch more claims; more touches means more revenue. Do this for commercial payers as well as for Medicare and Medicaid.
- Identify specialists from neighboring departments (patient access and coding, for example) to work claims that have been denied for reasons associated with those departments. Maintaining clear channels for communication among teams will speed denials work.
- Use your technology (from above) to drive prioritized and stratified denials to these payer- and department-based teams. There is nothing complex about the workflow: follow up, document, move to the next claim.
- Encourage teams to identify and bring forward any potential trends and/or issues. These should be viewed as opportunities to improve programming, ultimately reduce denials.
- Establish project KPIs at the outset, share them with your teams, set appropriate team and individual goals, then measure them using your technology.
Having the right technology in place and building a better team structure will drive your claims resolution higher and increase revenue. Let us know if you’d like to learn more, and we’ll show you what the right denials management process can do for your organization.
Remember, denials happen, but we’re here to make sure you have a comprehensive system in place that will let you efficiently address them.