5 tips on reducing claim denials

Claim denials remain a key issue for hospitals and health systems as they aim to maximize revenue.

Here are five tips to reduce denials.

1. Charles "Chuck" Duva, MD, CEO of DuvaSawko Emergency Medicine Billing, suggested medical practices focus on rolling accounts receivable as they strive for accurate and effective revenue cycle reporting. "Your billing department should be diligently following up on the denials, and should be able to let you know which types of denials are affecting your collections and cash flow the most," he said.

2. Robert Doxey, senior regional director of Recondo, suggested using robotic process automation to perform business operations duties. Healthcare organizations can use RPA to more easily determine a patient's potential financial responsibility "to eliminate a lot of that manual effort and to get data directly from payer websites automatically," Mr. Doxey said. "In the billing process, for example, automating authorization from initiation to submittal can also reduce authorization-related denials and denial write-offs."

3. Blockchain and advanced artificial intelligence algorithms provide the answer for healthcare organizations seeking to reduce claims denials and ensure maximum provider reimbursement, according to Deepti Sharma, director of product management at HSBlox. Ms. Sharma said: "By leveraging these two technologies, healthcare organizations can deliver both a retrospective and prospective view that can help improve operations and outcomes — all while ensuring the ultimate in compliance and meeting applicable reporting requirements."

4. Kenneth Miller, senior revenue cycle management specialist at Cantata Health, said hospitals should focus on the back end as well as the front end of the revenue cycle when looking to reduce claim denials. "To truly understand the origin of your denials requires periodic tracking of progress on your back end," he said. "Say you start with an issue that caused 20 percent of your claims to be denied. If, after deploying significant man hours on a front-end remedy you're still at 19 percent denials, something is wrong. You'll never know what's working and what isn't if you don't pause for a moment and look back. Scheduling project reviews at set intervals after the project go-live will ensure that your goals are being met."

5. Ed Gaines, chief compliance officer at Zotec Partners, addressed the emergency department revenue cycle during the Becker's Hospital Review 9th Annual Meeting on April 12 in Chicago. He specifically discussed CMS' Targeted Probe and Educate program, which is focused on reducing claim denials via help with a Medicare administrative contractor.

"What's concerning about the TPE process is at end, if they deem you have not been fully educated or otherwise modifying your behavior, they can refer the matter to the uniform program integrity contractor or do a statistical sampling, allowing them to extrapolate an error rate across your universal claims," Mr. Gaines said. "That's when the dollars get really significant."

He suggested overcoming this by educating auditors on ED coding, as well as focusing on the TPE timelines, taking in the CMS' education and implementing any necessary policy changes.



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