6-Step action plan for a successful denial management solution

Revamping the claim denials process is at the top of most hospital CFOs' minds in 2015.

After all, effectively managing your claim denials can increase your organization's revenue and collections rate while improving patient satisfaction. And that, in turn, can lead to fewer denials to worry about in the future.

But before we look to the future, let's look at some tips to help streamline your process to promote a healthier, more efficient denial management strategy—today.

Tip No. 1 – Understand why these claims were denied in the first place

Knowing why your patient's claim was denied is important if you want to streamline your process to:

a.) Maximize your collections revenue
b.) Prevent future claims from happening

Remember, not all of your patients are knowledgeable in regards to the insurance denial system, so you need to do your job to educate them on how they can solve the issue. Thanks to Hospital Consumer Assessment of Healthcare Providers and Systems Hospital Surveys, patient satisfaction is more important than ever, so being able to help your patients in a timely and effective manner is vital to the overall success of your organization.

Tip No. 2 – Keep your denial management process organized

Losing track of denied claims is like losing cash from your back pocket. Once or twice, it's frustrating. But as it keeps happening, you'll have a serious problem on your hands, as those denied claims have a way of piling up over time. If you don't have an organized system in place to keep track of your denials, you won't even know when they're missing in the first place.

Many hospitals are adopting tools and technologies to help them see when and why their claims are being lost amongst the shuffle. This helps hospitals manage their denials and keep an eye on which ones still need attention. And keeping your denials moving at a brisk pace is the best way to maximize your denial collections revenue.

Tip No. 3 – Complete claim denials within a week

Creating a strong workflow for you denied claims is paramount to establishing a successful denial strategy. When you receive a denial from an insurance company, you should have a process in place to ensure that denial will be corrected within a week.

To do that, you need to establish a workflow that can track your claims as they enter and leave your system. It's important because, not only will it lead to a more effective system, but many insurance companies set limits on how long a hospital has to appeal a denial. And losing money you're owed because you're a day past the "time limit" isn't a conversation any party wants to have—except maybe the insurer.

Tip No. 4 – Track your progress and success

Keeping track of your process is important, as it helps organizations see which areas are working, and which need further support. That's why you should be documenting both your wins and losses, in regards to your unpaid claims. The ultimate goal is improving the efficiency of your organization, and sticking close to the analytics is a great way to prove the value behind your strategy.

- Are claims being denied for the same reasons?
- Are denials being taking too long to complete?
- Are denied claims getting lost or expiring?

These are questions you should be able to answer on the fly, so if you haven't kept track of your progress yet, you'll want to start as we move further into 2015 and towards ICD-10.

Tip No. 5 – Identify most common denials and trends

Identifying the types of denials that are most common to your organization is also a crucial component of establishing an effective denial management process. Each health organization is different, but in general, the top causes for denials are:

- Coordination of Benefits
- PIP Applications
- Accident Details
- Pre-existing Conditions
- Name Misspellings

Each of these denials may seem like a small problem initially, but as you continue to track and analyze these trends, you may reveal larger issues in your organization. Do some due diligence, and create a checks and balances system in your denial management strategy to ensure you're not just thinking what's trending now, but also what will be trending five years from now. Plan ahead, and you may see your list of common denials start to shrink.

Tip #6 – Outsource your denial management process

Outsource an expert healthcare business process outsourcing company that specializes in revenue cycle services, including expertise in denial management. When choosing which outsourced solution to use, there are two questions you should ask:

1. Will it bring in more money from patients and payers?
2. Will they give exceptional customer service to ensure and exceed patient satisfaction?

The top denial management providers use specialized teams that are highly trained in working with, negotiating and navigating the complexities of the insurance system. By outsourcing your denial management services, you'll have more time to focus on other areas of the hospital that require your attention.

Alyssa DiSalvatore is the Director, Sales and Brand Management for BYL Risk Management's subsidiary company, VARO Healthcare. She specializes in generating new business by identifying opportunities to help healthcare providers manage their revenue cycle and accelerate cash flow. www.linkedin.com/in/alyssadisalvatore/

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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