Claim denials are undeniably one of the trickiest and complex processes involved in healthcare revenue cycle management. Most of the healthcare organizations intend to keep denial rates between 2% and 4%. However, the reality is otherwise, especially in the last five years. Consider that more than 33% of healthcare organizations are nearing the “danger zone” with an average denial rate exceeding 10% in 2020. Hospital denial rates are at an all-time high, and here are the key reasons for denials.

Common Denial Patterns in Healthcare Revenue Cycle

• Duplicate Claims. This could be a result of submitting claims more than once for the same encounter
• Overlapping claims. This kind of conflict in claims could arise due to clashing dates between claim submissions made by different providers
• Claim Filing Date Expiry. There is always a set time frame in making claims on payables after you have done the service. If you have failed to submit before the due date, the insurer then will not be liable for the medical expenses.
• Non-covered Services. Some of the medical services may not be covered by the patient’s insurance plan, claims which get denied by the Payers.

Medical Claim Denials: Statistics You Don’t Want to Ignore!

One-third of medical claims are rejected or denied according to a CMS report. These claim denial rates have only risen to new heights during the global health emergency. Eligibility and prior authorization challenges are amongst the topmost reasons for claim denials.

The financial impact of Claim denials and rejections is more significant than one can imagine. It has a ripple effect on the revcycle performance and in turn the cash flow, revenues and the financial health of a healthcare organization. Furthermore, this could also result in negative Patient Experience (PX) and satisfaction. Here are some simple steps you can take to prevent claim denials.

While the checklist above helps mitigate the cost impact of denials, it is essential that Hospitals and Medical Practices take a more holistic approach to denial management. Denial management is an extensive process that involves complex strategies and advanced workflows that optimize efficiencies. However, the good news is that 90% of claim denials are preventable. A comprehensive denial management strategy identifies the root causes of denials specific to your Practice, combines the right technology capabilities—to elevate the process from denial management to denial prevention on the whole.

At SolvEdge, our denial management services are uniquely designed to reduce the spiking denial rates, while having a proactive approach to denial prevention. Our customized workflows help determine the root cause of denials. Once the denial patterns are identified, we create a detailed report that evaluates the recurring causes of claim denials under various categorizations like the Payer, doctor, diagnosis and CPT codes. By leveraging these insights, we implement process improvements to reduce denials and optimize revenues.

Why SolvEdge Denial Management Services?

Our denial management team works towards one goal of relieving the burdens of claim denials from our clients—and letting them single-mindedly focus on patient care. Our 4Clover Approach to Denial Management Services includes Four Phases - Analyze, Strategize, Discover and Implement to ensure a holistic and multidisciplinary approach to your revenue cycle process.

Also Read:

Determining the Root Cause: A Guaranteed Strategic Approach to Denial Prevention

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Denial Codes: Optimizing Efficiencies Using Medical Billing Denial Management Services Strategies

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7 Best Practices on Claim Denials you need to Know Right Now!

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33% of Hospitals in “Danger Zone” with 10% Claim Denials: Here’s How to Change the Trend

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Top Ways to Streamline Coding and Denial Management Workflows in Orthopedic Billing