Denial management is the process of investigating all unpaid claims, and it is a vital aspect of revenue cycle management. Using denial management, practices, and hospitals can swiftly pinpoint why claims are being denied so that these mistakes don’t happen again. However, every patient is different and presents unique challenges to providers, meaning every claim is just as unique as the patients themselves. There are many obstacles that denial management has to overcome.
Patient Responsibility is on the Rise
Because of high deductible health plans that require patients to share responsibility for payments, there is more pressure placed on the patients. As patient payments continue to increase, it becomes increasingly difficult to gather payments on time. Currently, resolution programs are in place that is seeking to get revenue cycle vitality.
Outdated Denial Management Strategies
Many practices are still using paper-based processes, which are less efficient and organized. These processes don’t have the same automation and decision support that virtual systems possess. The end result of paper-based processes is non-optimal denial management.
Value-Based Care Influences the Profitability of the Revenue Cycle
While value-based care does have its positive implications, certain service lines might not be as profitable. This results in standardized payments and costs.
Denials are Rising as a Result of Complexity
Many insurance companies have more complex requirements, which cause many practices to deal with initial denials. The reworks done to denials and appeals hinders revenue cycle improvement initiatives.
How to Overcome These Challenges
- The first thing you should do is find the initial denial rates and figure out the best solution to these denial problems. With the help of data analytics, you should be able to find the root of your denial problem. Once the cause has been identified, you should be able to determine who is impacted the most, whether it is the payor or provider. The clinical and revenue cycle areas should also be redesigned.
- Second, you should investigate registration and pre-service issues. Denials often occur the moment a payor isn’t responsible for coverage. It’s the front desk’s duty to pay close attention and confirm patients’ eligibility beforehand.
Preauthorization begins with particular procedures that get handled by providers, payor, and plan. Prior authorization is something the nursing staff members handle for many hours every week. This preauthorization, along with other medical denial accounts, relates to a certain percentage of all of the denials that are at the heart of failure as a result of not authorizing ahead of time.
The information is supposed to go from the provider to the payor, then back to the provider. Providers can improve efficiency by getting clinical guidance and support founded by evidence, which then solves more complex cases. Practices can opt to:
- Automate their screening processes for pre-authorization, making it easier for staff to verify everything in place.
- Automate payor policy maintenance in every location and raise accuracy to lower the amount of administrative work.
The staff has to make sure that all operational reports from revenue and finance cycles get circulated and reviewed regularly to provide a more clear path on which to focus. The team has to update and manage the data for the sake of raising the health of the practice and to ensure that future denials don’t happen.
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