Healthcare providers are experiencing a massive surge in denials and write-offs that seriously impact the organization’s financial stability. But there are steps your organization can take now to reduce their likelihood in 2024.
With a proactive and comprehensive approach, the following strategies serve as a foundation for navigating the complexities of the contemporary healthcare environment to minimize denials and optimize revenue.
- Enhanced Registration and Pre-Authorization Process
Preventing denials begins with a detailed registration process to ensure all necessary documentation and approvals are in place before a patient receives services. This includes verifying insurance coverage, obtaining pre-authorizations for procedures, and confirming that the patient's information is accurate. Organizations can identify potential issues early in the process, such as coverage limitations or expired policies. Addressing these issues before claims submission significantly reduces the likelihood of denials related to eligibility and pre-authorization requirements.
- Accurate and Timely Documentation
Emphasizing accurate and detailed record-keeping throughout the patient care journey is paramount in preventing denials. Redefining the importance for Clinical Documentation Integrity within your organization can further optimize the middle revenue cycle, ensuring accurate and comprehensive documentation that supports appropriate reimbursement. Timely documentation is equally critical, as delays will lead to claim submission deadlines. Lastly, optimization of the electronic health record (EHR) systems and creating a single source of truth creates a simpler process for providers and coding staff to follow.
- Claim Scrubbing and Validation
Claim review and editing is a next step. With a robust claim editing process, organizations can proactively identify and rectify errors such as coding inaccuracies, insufficient documentation, or other errors before submission. Comprehensive claims edits encompass a range of checks, including verification of patient information, coding accuracy and adherence to payer specific billing requirements.
- Data Analytics for Denial Trend Analysis
Leveraging historical data is a powerful tool for identifying denial trends as organizations can pinpoint recurring issues and root causes. By understanding these root causes, organizations can implement targeted strategies to address specific issues. This may involve additional staff training, process improvements, or technology optimization. Continuous monitoring and adjustment based on data- driven insights creates a proactive denial prevention approach that evolves with the ever-changing landscape of healthcare regulations.
- Comprehensive Training for Staff
Specializing denials staff, organizing denials around appeal approaches, and crafting impactful appeal arguments contribute to a standardized process for addressing denials efficiently. This requires investing in ongoing staff training and education to keep staff updated on the latest coding guidelines, regulatory changes, and payer requirements. A well-informed team is better equipped to submit accurate claims, reducing the likelihood of denials due to coding errors or non-compliance.
- Collaboration with Payers
Establishing strong collaboration with payers is essential to understand their specific requirements and expectations. Clear communication channels can help resolve potential issues before they escalate into denials. Set monthly or quarterly meetings with your payor representatives to discuss denial trends, opportunity to bulk process inventory, and identify pain points in payer contracts to help negotiate terms that address specific challenges. Also ensure you stay informed about payer policies and updates.
CHECKLIST: Steps You Can Take to Proactively Reduce Your Denials Now
- Enhanced Registration and Pre-Authorization Process
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- Develop a detail process map and checklist for registration to capture essential information.
- Create documentation with details around pre-authorization requirements that are at the payor and specific level.
- Implement rules and workflow in your EHR to flag missing information, coverage limitations, authorization requirements and streamline documentation process.
- Conduct regular training sessions for staff to ensure adherence to registration and pre-authorization protocol.
- Create standardized reporting to capture and monitor key patient access KPIs.
- Clean Registration Rate
- Average Registration Time
- Initial Denial Rate (broken down by patient access function)
- Accurate and Timely Documentation
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- Define and communicate the role of CDI within the organization.
- Implement CDI processes that provides real-time feedback to providers regarding the impact of their documentation on reimbursement, and audits to ensure compliance with documentation standards.
- Establish regular meetings to discuss documentation improvement opportunities.
- Create collaboration channels with coding teams to ensure alignment between clinical documentation and coding practices.
- Optimize EHR system to create a single source of truth and set workflow for timely coding.
- Provide continuous training to clinical staff on the importance of precise and documentation, incorporating audit results.
- Claim Scrubbing and Validation
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- Implement automated bill edits and rules to identify billing errors and discrepancies.
- Confirm modifiers are appropriately applied to convey additional information when necessary.
- Identify and understand payor specific billing requirements and incorporate validation in the pre-bill process.
- Establish a process and schedule for regular audits of claims data to identify patterns and potential issues.
- Create standardized reporting to capture and monitor KPIs related to the billing process:
- Clean Claim Rate
- First-Pass Rate
- Pre-AR Days
- Charge Lag Days
- Data Analytics for Denial Trend Analysis
- Implement a process to analyze historical data to identify patterns, tends and comment reasons for denials.
- Facilitate monthly denial prevention meetings between revenue cycle teams, IT, clinical staff, and additional appropriate departments to provide trends, insights and address root cause issues.
- Implement additional staff training, process improvements, or technology optimization based on identified root causes.
- Ensure transparency and accountability of change management process to measure the effectiveness of the prevention strategies.
- Establish benchmarks and targets for KPIs specific to denial prevention.
- Initial Denial Rate
- Top Denial Reason
- Payor-Specific Denial Rate
- Denial Rate by Function
- Overturn Rate
- Comprehensive Training for Staff
- Conduct a needs assessment to identify specific training requirements for departments.
- Utilize the audit process to identify trends and knowledge deficiencies.
- Design and implement a comprehensive training program for coding guidelines, regulatory changes and payer requirements.
- Prioritize cross-functional training sessions to foster collaboration between billing, coding and clinical teams.
- Cover the end-to-end process of claim submission, including eligibility verification, authorization, and coordination of benefits.
- Provide insights into the specific requirements and nuances of major payers.
- Instill a culture of continuous learning and professional development.
- Collaboration with Payers
- Establish dedicated communication channels with payers for prompt issues resolution.
- Create a standardized process and centralized repository for payer communications and updates.
- Develop a process for dissemination payer updates and policy changes to relevant staff members.
- Setup up structured monthly or quarterly meetings with payer representatives to discuss denial trends and resolution hurdles.
- Keep managed care abreast of any hurdles and contract negotiation opportunities to prevent future denials.