Denials ManagementJuly 8, 2015

Agenda• The Cost of Denials• Denials are growing• Most denials are appealable• Prevention is the Best Medicine• Types of Denials • Source of Errors Leading to Denials• To Insource or Outsource• MedPerformance iMAD

2

The Cost of Denials• Your hospital is most likely losing around 3% of its net revenue

due to denials– How much is 3% of your net revenue?– How much does that change your net income?

• You owe it to your organization to effectively manage denials• The cost to collect is growing too

3

Denials are growing• Many of the plans offered by certain payors reject about one

in five claims• Gross charges denied by payers have grown to an alarming

rate• Your reimbursement is not increasing enough to offset denials

4

Most denials are appealable• Most denials are appealable– Recent estimates are around 67%

• You need to put a strong appeals process in place• You need to research, investigate, and appeal denials• You need a system to track, trend, and follow-up

5

Prevention is the Best Medicine• 90% of denials are preventable• Once we put in a denial management system, we were able to

start tracking our denials. We realized that we were a huge part of the problem. It was not all the payers’ fault. We realized we needed to get our act together before we starting blaming the payors.– Quote from a hospital CFO

6

Types of Denials• 23% - Medical Necessity • 25% - Eligibility • 19% - Authorizations • 33% - Demographic Information

7

Source of Errors Leading to Denials• 51% - Private Insurance• 30% - Medicare• 16% - Medicaid• 3% - Other

• 71% - Outpatient• 29% - Inpatient

8

To Insource or Outsource• The Shortcomings of insourcing as the Sole Denial

Management Strategy– Internal denial teams have proved generally successful – Experience shows they overturn, on average, a bit less

than 50% of all denials– roughly 67% of all denials are appealable, nearer two of

every three referred denials, so not performing as expected

– Denials is a labor-intense process slowed by staff members’ competing priorities

– A great denials management system improves efficiency and recoveries

9

To Insource or Outsource• Outsourcing as a Strategy – Focus of an external team– Proven performance– 20% average reduction made possible by combining

software technology with dedicated denial staff assistance– You can outsource your entire denial management process

to MedPerformance

10

MedPerformance iMAD• MedPerformance has a powerful and easy to use Denial

Management System “iMAD” that can help you reduce your denials

• MedPerformance can help you with manage your denials with experienced staff

11

iMAD Contact InformationFor more information, please contact:

MedPerformance LLCRebecca Corzine Tarr

Owner(813) 786-8974

Becky@MedPerformance.comwww.medperformance.com

12