The most effective method to reduce claim denials is to improve a hospital’s clean claims rate. Submitting accurate and complete claims the first time around is the secret to lower claim denial rates. However, no matter how diligent a hospital is – claim denials will happen. So what can a hospital do to lower claim denials and improve their clean claims rate?

Businessman with a card that reads, claim denied, for advice on lowering claim denial rates

When a hospital has a claim denied, that revenue can be lost. Forever. That is if appropriate actions are not taken promptly.

[Receive Information About: How to Choose a Denial Management Solution]

Every day in our line of work we see common occurrences that account for the majority of claims denials. We look to other industry thought leaders and combine our professional experience to bring you:

Expert Tips on How to Lower Claim Denial Rates

1. Uncover the Root Cause of Most Denials

Susan Eilman, a senior healthcare consultant for revenue cycle transformation at Hayes Management Consulting, shared revenue cycle management advice with Becker’s Hospital Review in a recent interview. She explains how important it is to get to the root cause for most denials by continuously asking the question, “why”.

Eilman shares a story about her recent work with a revenue cycle director that identified a specific clinic with a denial rate of 42 percent. When asked why the location had this high rate when the industry standard is less than five percent, the director researched and quickly discovered that the newest access management staff was incorrectly terming the insurance that had gone inactive. The problem was quickly resolved with adequate training on the use of the facility’s insurance verification tool, terming of inactive insurance, and the collection of copays at point-of-service. According to Eilman:

“Continue to ask ‘why’ for every denial until the root cause is exposed. Once the solution is determined, then strategize and develop a plan of action to diminish the reoccurrence.”

2. Take Action to Lower Claim Denial Rates Before It’s Too Late

Early action is key to resolving the issue and receiving payment. A robust denials management system provides prompt identification of denials which helps hospitals take appropriate action for effective claims management. Hospitals that lack the technology or do not have a system in place to understand the codes from payers are at risk of losing out on revenue due to errors not corrected early on.

3. Improve Patient Access Processes to Foster a Higher Clean Claims Rate

According to a recent article in RevCycle Intelligence, revenue cycle management has been traditionally divided into the front-end and back-end, with the back-end focused on claims.

[Read alsoImprove Your Healthcare Organization’s Claims Denial Management Processes]

However, to improve a clean claims rate, the front-end needs to be more aware and focused on the data that is entered at the time of registration. The article quotes Rebecca Wright, Vice President of Strategic Planning at Iroquois Memorial Hospital, who said:

“In the past, it’s always been focused on back-end or business office and in collections, and we turned it on its head and looked at how we can push it more to the front-end. Because we knew by pushing more of it to the front-end, we could reduce overall costs for our organization and make outcomes a little bit better.”

4. Track Progress of Each Denial Appeal

The President of Kemberton, a provider of specialized revenue cycle management and revenue recovery services, Brandon Rife offered advice in a Becker’s Hospital Review article that emphasized the importance of watching each appeal to determine whether it was successful in order to build on those accomplishments. He stated:

“Know what you’re good at, know the payers you’re having success with and go back … and identify the accounts that are denying with that payer with that same issue. Don’t do appeals in a fragmented, disconnected environment. Do it where there’s a reported methodology where the hospital is benefiting from the knowledge that group of people doing appeals is gaining.”

5. Designate Specific Employees to Work on Claim Denial Management

Mr. Rife also suggests that while most hospitals have many employees that work on claims denials – they are usually performing various tasks and not only appeals. He suggests that the people working claims should be highly trained to become an expert in the subject matter and build a strong base of foundation from their experience. “The hospital will benefit from it. That subject matter, that knowledge that they [the employees] gain won’t walk out the door,” he explains.

Robust Claims Management Solutions are Vital to Lower Claim Denial Rates

Is your hospital equipped with the software needed to submit clean claims and reduce denials? At The SSI Group, we offer the following claims solutions:

  • SSI EDI Clearinghouse: A solution that handles hospital claims submission and processing
  • SSI EDI Gateway: Helps ensure claims are complete, accurate, and standardized to the appropriate system
  • SSI Claims Director: Helps guide users through the electronic claim submission and reconciliation process from start to finish
  • SSI Claims Director: Epic: Integrates seamlessly with Epic billing system
  • SSI Claims Director: Cerner: Sold directly through Cerner and tailored to Cerner users
  • Additional functions, including:
    • Correspondance Conversion: Enables the extraction of data from scanned paper correspondence letters
    • EOB Conversion: Extracts data from scanned explanation of benefits (EOB) documents
    • Claims Status Plus: Accelerates timeline for receiving payments with automated follow-ups to Medicare and commercial payers
    • Attachments: Used by providers to send additional documentation to payers when needed
    • Pre-Billing Eligibility: Helps to reduce denials and unnecessary write-offs due to coordination of benefit discrepancies

Request a demo today to see how our revenue cycle management solutions can lower claim denial rates.