Pursue every denied claim
Healthcare providers need to develop plans for pursuing each rejected claim and set up a system that classifies each claim according to the reasons for rejection, taking into account both low-value and complex clinical denials. You can develop a denial appeal procedure that is specifically tailored to the institution’s type of services and the payers it frequently deals with by using historical data on the success rate by payer and denial grounds.
Templatize your denial appeal process
You can improve the procedure for appealing similar claims by taking lessons from previously rejected appeals. You can create a denial appeals procedure that works effectively and efficiently in the future by keeping a database of successful requests by the payer and refusal reason.
Focus on clinical denials
Clinical or coding rejections demand a targeted appeals approach that draws on knowledge of the particular specialisation. You can strengthen your clinical denial appeals by enlisting the assistance of qualified medical coders who are knowledgeable in the relevant speciality. Talented coders might increase your chances of getting paid by establishing medical necessity for the specific procedure in discussions with the clinicians.
Establish a denials prevention program
Members of the denials and appeals team must develop a framework for collaborating with front-end revenue cycle staff, doctors, and coders.
- Record each denial’s underlying cause and talk about it with your front-end and mid-cycle RCM teams to determine ways to prevent future instances of the same denials.
- The team’s understanding of particular procedures will be improved through regular meetings and review sessions with the doctors, which will also assist them create compelling arguments when filing appeals. Since over 60% of denials result from preventable causes or behaviours, the group can apply an 80:20 analysis to come up with solutions for the most common denials and prevent expensive errors.
Apply automation and analytics
The team’s efficiency and effectiveness can be increased by implementing predictive and intelligent procedures, which can assist the team specialize in payer-specific denials issues and develop tailored templates for successful denial appeals. You can maximize human effort with workflow automation, and you can create appeals in formats tailored to particular payers with robotic process automation. Analytics will enable you to appeal denials in a way that maximizes your chance of recovering lost revenue.
Measure the success
Your attention will immediately turn to rejection prevention when you increase the success rate of appeals and take corrective action to remove the reason for claim denials. Give your team access to automatic reports so they can identify the root of the problem and take precise steps to solve it. You can turn learning into a denial prevention plan by institutionalising the denial rate measurement, investigating the root reason, and removing it.
