Claim denials plague every hospital. As reported in a 2016 article in Becker's Hospital CFO Report, payers deny or delay upwards of 20 percent of all submitted claims. Organizations that wait for denials to occur before taking action may be as much to blame as the complexities of payer rules and regulations for lost or reduced revenue. Leaders within revenue cycle departments should take every measure to prevent denials in the first place. Fewer resources go into prevention than that which goes towards correction on the back end.
What are the most effective ways to prevent claim denials on the front end?
1. Gather Correct Registration Demographics
As simple as it sounds, conscientious collection of patient demographics at intake can prevent a huge number of denials. Utilizing technology to automatically flag detectable errors, such as missing initials, or data entry that fails to match previous patient records can reduce these types of denials considerably, leaving the back office staff time to work the stickier denials.
2. Verify Eligibility
With more government involvement in health insurance and delivery systems, patient policies and coverages have undergone rapid changes in recent years. Verifying patient eligibility can't be an afterthought. Someone should always confirm eligibility for each registration to avoid nasty surprises down the road.
While everyone prefers that doctors and clinical staff have the focus to deliver superior care without the mental clutter of codes and terminology, the sad reality remains that payers, both private and public, demand thorough documentation in their own proprietary language. Failure to do so can torpedo a claim and cause a tremendous amount of effort to rework it. Here's where technology can once again offer tools to prompt clinicians for proper documentation according to the payer requirements and lexicon, rather than leave it to the guesswork.
4. Code Properly the First Time
Coding errors account for a significant number of denials. Staff training will go a long way towards amending the problem; however, with IDC-10 upsetting the coding applecart, and many other payer changes, keeping on top of correct codes and usage may seem nigh onto impossible. Partnering with a vendor who specializes in keeping current with ever-changing codes could be the best way to prevent future denials.
5. Scrub Them Clean
Once a claim seems properly prepared and ready for submittal, it should go through a claim scrubbing application. Taking one last look at it can catch mistakes that became invisible to the humans who put the claim together. Between human and machine scrutiny, claims stand a better chance of succeeding the first time out.
6. Submit on Time
If the billing staff can't work claims fast enough to submit them within the prescribed window of time, you may need to increase your staff, upgrade your technology or consider outsourcing. Really, there's no excuse for failing to meet the deadlines.
7. Analyze Denial Reports
Your denial reports offer you the opportunity to discover your weakest spots. The information in each report should be added to a database that can expose patterns. If most denials come from demographic or technical errors, you can focus your prevention efforts there. Likewise, if coding is your downfall, you can dig into the source of the errors and take the proper steps to shore up training or technology. Without data analysis, you end up stomping out fires as they spark, but seldom preventing them in the first place.
Once you clean up claims before they go out the door, if they continue to return unpaid, then perhaps the problem stems from payer mistakes, real or fabricated. If you suspect such, then you should seek help from a vendor capable of advocating for your health care organization to recover your improperly denied claims. Sometimes, a little help from a dispassionate third party can cure seemingly intractable problems.