The UnacceptableTruth About DenialsBy Kristen E. Hughes, Senior Client Services Manager, MediRevv

Instead of counting sheep, are you counting the lost dollars and too

many days in A/R that threaten the health of your revenue cycle?

IF YOU’RE NOT, YOU SHOULD BE.

Are you seeing the word “denials” inyour sleep these days?

CAN you afford that?

DID YOU KNOW?$25 x 100 claims = $2,500Average cost

of rework

Average number of claims that

require rework per monthAverage cost per monthto work unclean claims

Source: MGMA Connection, February 2014

ALSO...Only about 2/3 of denials are recoverable

BUT 90% of themare preventable

Source: At the Margins, Advisory Board Company, December 11 2014

There was a time when you sent claims out to payers andconfidently expected full reimbursement for your services.

Maybe even an annual reimbursement rate increase to boot.

THOSE DAYSARE GONE!

Not only are Medicare payments projected to remain flat forthe foreseeable future, navigating through increasingly

complex reimbursement requirements has becomeultimately challenging.

With changing reimbursement

rules and complications

associated with ICD-10, it’s

imperative that provider

organizations do everything

they can to capture 100% of

revenue owed to them by the

insurance companies.

That’s why a solid DenialsManagement Strategy is

absolutely vital.

Here are a couple reasons…

Understanding why denials happen is a

good first step in developing your strategy.

Registration issues

Getting things like patientidentification, patient

insurance eligibility and validinsurance coverage right atthe outset is the beginning

of sucessful denialsprevention

Coding challenges

Claims with incorrect, incomplete, or missing codes are denied.

The best way to reduce coding-related denials is to make sure

your claims are clean right out of the gate.

It’s absolutely vital to have the right, highly trained coders on

staff, and a quality assurance (QA) auditor is icing on the cake.

The physician credentialingprocess can be an arduous, slow

process, usually entailingconsiderable paperwork and

extensive review of theclinician’s accreditation. The

process may have to berepeated when the

credentialing expires, oftencausing a denial.

Credentialing considerations

Denials increase when you don’t have a well-conceived process

in place that ensures your admission precertifications and

procedure authorizations are consistently handled

appropriately and don’t fall through the cracks.

Precertification problems

Those are just some of the many reasons denials happen.

Here are several more:

Charge Entry

Referrals & Pre-authorizations

Info from Patient

Duplicates

Medical Necessity

Documentation

Bundled/Non-covered

Obviously, your game plan

should include both

eliminating denials to the

greatest degree possible by

submitting clean claims

initially, and also reacting

quickly and correctly when

denials do occur.

Yet for a strategy to succeed you’ll need

considerable expertise and significant resources.

For many providers, thispresents a challenge.

In an environment where

many healthcare

organizations are already

feeling the budgetary pinch

and resource challenges,

how, you may be wondering,

can you accomplish all this?

One great way is tooutsource some or all of

these business officefunctions, but it’s important

to find a firm with thecharacter, integrity,

expertise and proven trackrecord of results.

http://www.connect.medirevv.com/how-medirevv-adds-to-your-bottom-line