Image of two stamps. one on its side. on a paper is stamped in red in reading Denied

Payer Denials: Can You Win on this New Battleground?

In today’s complex health care environment, in which CMS and insurers each maintain their own claims-related “rules,” disputes, DRG downgrades and denials are all-too common.

Recent studies show that up to one out of every five claims is delayed or denied, and in certain categories (such as operating room services and laboratory tests), one-quarter to one-third of claims are rejected. Some providers concede defeat: they fail to re-submit claims or appeal denials altogether, simply because each such effort adds to their already-high administrative costs.

Finance and RCM leaders need concrete tools to prevent, identify and resolve claims disputes efficiently and cost-effectively.

Here are some of the strategies you can employ today:

  • Understand the most common reasons why claims are denied. Failures to collect full, accurate patient information or verify insurance coverage can lead to data-entry errors and after-the-fact determinations of patient ineligibility and non-covered services. Other administrative errors, including coding, delayed filing and billing, and claims duplication are also common problems.
  • Train staff thoroughly. Simply put, staff must understand how to create and submit clean claims. Key employees should receive regular training to ensure that their coding and submission-process knowledge is up to date.
  • Conduct regular audits of claims. Be proactive, and check your team’s work. If you can identify and address commonly occurring issues before claims are submitted, you’ll reduce your denial rate and put yourself in a better position to launch an appeal.
  • Act quickly. Payers often require providers to appeal, adjust and/or resubmit claims within a very tight timeframe, often in less than 90 days.
  • Create appeal workflows, checklists and tools. Don’t just hand off or kick back claims resubmissions and appeals. Establish a clear workflow, identify subject matter experts, and assign responsibility for claims resolution.

Written by: Sandra L Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer