In a recent webinar, Mary Guarino, vice president of product management at Craneware — a healthcare billing, auditing, chargemaster management and Medicare compliance provider — and Dustin Wuest, professional services manager at Craneware provided insight on ways hospitals can improve their claims denial management.
1. Correct all denials within five days. If a bill is returned to a hospital because it was submitted incorrectly to an insurance company, the bill should be corrected and resubmitted to the payer within five days. "The way to do this is to create a strong workflow process," said Mr. Wuest. Part of the process is implementing a common communication platform across an entire system to help ensure the denial and the communication that relates to the denial are being adequately tracked.
Many health insurers set time limits for hospitals to appeal a denial, and hospitals should always track the appeal time limit. Mr Wuest said this can be done by using an aging report that shows how long a claim has existed.
2. Don't lose track of claims. A claim that gets lost in the system is "really lost money," said Mr. Wuest. This typically occurs when claims are put into the system and no one knows it is there, or when there is not enough staff to cover all of the claims. To help address this issue, Mr. Wuest suggested using a tool that requires transparency to let hospitals to see why claims are being lost in the system. By allowing a hospital to see what stage a claim is being lost at and the cause for any delays, a transparency tool can provide hospitals the information they need to improve their claims denial processes.
3. Define the problem. Hospitals should look at their denials every month. They need to "determine the net loss by payer, the net loss by patient type and the net loss by clinical area to really understand denials," said Ms. Guarino.
"I think of everything as an opportunity," she said. Tracking claims allows hospitals to see the root causes of denials and to focus on getting the right information to the insurer the first time. "Front-end avoidance is very important in denial management," she said.
4. Document successes and failures. A hospital's "financial performance is based on working denials," said Mr. Wuest. By documenting what processes are working and keeping track of lost claims or other denial management failures, "it's going to improve the process and hospitals are going to be more efficient," he said. In the realm of claims denial management making even small improvements will help.
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