Is your hospital using claims denial management tools?  According to Healthcare IT News,  “More than half of hospitals are not currently using revenue cycle vendors claims denials management tools, according to a new survey from Healthcare IT News sister company HIMSS Analytics, and that reality presents a large opportunity for providers to get more expedient payment. ”  As the grace period for ICD-10 ended last fall, errors are the top of mind when using the newly expanded coding system for hospital claims denial management.

Denial and claims management are key factors in the hospital revenue cycle process.  While traditionally thought of as a back-end focus area, more hospitals are taking a proactive approach to identifying possible problems up front.  Luke, Meert, Revenue Cycle Director for Botsford Health a, 360 bed facility in Michigan, made a co-presentation (PDF slides) on “Moving from Denials Management to Rejection Prevention” at HFMA National Institute last year.  He stressed that, “Rejection Prevention is a shift from a system designed to ‘work’ denials to a system that is designed to provide meaningful data into the organization in order to identify the rejections that can be prevented and to take meaningful action in improving upfront revenue cycle processes.”

We were pleased to see this call for a proactive front-end approach, as it underscores our strategic development of modules for both Access Management, where our Authorization and Precertification module can reduce claim rejections and improve cash flow, and our Claims Management suite of modules including, one focused specifically on Denial Management.  We believe that the current healthcare landscape calls for hospital CFOs to revamp the claim denial process, especially as a large portion of payer denials are “appealable.”

The SSI Group was cited as a prominent vendor for revenue cycle software in a Healthcare IT News article on “Claims denials management tools: Big opportunity for hospitals to automate revenue cycle processes.”    The article cites a survey by its sister site, HIMSS Analytics that found for denial management, “that 44 percent of participating hospital executives indicated they use a vendor solution while 31 percent have a manual process, 18 percent use a homegrown tool and 7 percent are unsure.”  They wrote that a focus on smart denial management solutions is now needed as “a modern and effective way to handle denied claims in lockstep with the transition to value-based care.”

This focus extends also to the payers who may make their own errors:

“Claims can be denied incorrectly,” Michele Redmond, vice president of Solutions Medical Billing explains. “If the person responsible for reading the explanation of benefits (EOBs) doesn’t understand or recognize the error, the provider may lose out on that money.” — Redmond is also an author of 15 books on medical billing (from an interview in Modern Medicine)

 SSI Group Case Study:  For Adventist Health System (AHS), an Altamonte Springs, Fla.-based system that operates 45 hospitals, accurate and efficient claims handling is a critical part of both ensuring patients receive the best care possible, and maintaining the financial health of the organization. AHS has deployed a full suite of revenue cycle management solutions, including EDI, billing, and claims management from The SSI Group, LLC (SSI). Using these tools, AHS has accelerated accounts receivable (A/R) processes and decreased the number of claim denials system wide.get more details

In reviewing recent best practice articles, we compiled the following list of tips, tactics and resources:

  • Top 5 medical billing denials (from Focus Ahead for Better Health Blog):  Missing information;
    Duplicate claim or service; Service already adjudicated; Not covered by payer; Limit for filing expired.
  • From Becker’s Hospital Review:  Understand why claims were denied in the first place;  Keep your denial management process organized; Complete claim denials within a week; Track your progress and success; Identify most common denials and trends.
  • Make Improvements on Denial Management Process (from HFMA presentation cited above):  Identify Back-End partners for Front-End; Co-assign Front-End rejections work queues to Back-End partners; Schedule periodic “Queue Review” meetings with BackEnd and Front-End
  • CMS (Centers for Medicare and Medicaid Services) ICD-10 Frequently Asked Questions and help site.

We think more hospitals will embrace denial management solutions in 2017.  As the HIMSS Director of Research observes, “Given the complexities around submitting claims and the labor associated with managing denials, it came as a surprise that more organizations have not automated the denial management process through a vendor-provided solution,” said Brendan FitzGerald, HIMSS Analytics Director of Research.”

Going to the ANI 2017 Conference in June?  Come see us at booth #423, and we can chat about ways to think out of the box to drive success where it matters most.  If you would like, schedule a meeting with us now to talk about hospital claims denial management.