Flip Your Lens to Clarity Over Denials

In the complex world of healthcare, professional service providers face a critical challenge: managing claim denials. These disruptions impact cash flow, increase administrative burdens, and create operational inefficiencies.  

By understanding payers’ denial strategies and adopting proactive management approaches, providers can turn this challenge into a pathway for optimal reimbursement. Here, we explore effective methods to streamline denial management, leverage advanced technologies, and foster continuous education. 

1. Strategies Employed by Payers

Payers implement sophisticated strategies to minimize claim approval, such as: 

• Prior Authorizations: Stringent requirements must be met before certain treatments or procedures are reimbursed. 
• Documentation Requests: Specific documentation is often required to verify claims. 
• Enrollment and Eligibility Verification:

To respond to these strategies effectively, providers need a proactive approach, integrating advanced artificial intelligence (AI), continuous staff education, and synergy between clinical and revenue cycle teams. 

2. AI Tools: Revolutionizing Denial Management

AI offers powerful tools to help providers predict, prevent, and manage denials: 

• Data Management and Payer Analysis: AI identifies payer behavior patterns, enabling providers to address potential denials before they occur. 
• Documentation Automation: Automated checks ensure documentation meets payer requirements, reducing compliance risks. 
• Risk Coding Enhancement: AI detects coding inaccuracies, helping avoid costly coding-related denials. 
• Contract and Policy Tracking: AI can monitor real-time policy changes, keeping claims compliant. 
• Root Cause Analysis:

Though providers may be wary of AI, recent findings show increasing acceptance. Dr. Scott Schell, Chief Medical Officer of Cognizant and TriZetto Provider Solutions, reports that automation is a significant priority for healthcare providers. In a recent interview with Fierce Healthcare, Dr. Schell cited a 2023 Cognizant survey of 300 executives that revealed 90% view automation as essential for operational efficiency and financial performance. 

3. Practical Automation Strategies

Effective automation spans various operational areas, including: 

• Identifying Priority Solutions: Start by pinpointing critical needs within your system. 
• Selecting the Right Technology Partners: Collaborate with partners who offer solutions tailored to your goals. 
• Change Management:

Organizations that succeed with automation focus on establishing a center of excellence, setting clear KPIs, and tracking progress to ensure smooth integration. 

4. Machine Learning vs. Bots: Choosing the Right Tool

When considering automation tools, decision-makers should assess each option’s specific use case and conduct a thorough cost-benefit analysis. In robotic process automation (RPA), automating “choke points” often yields the highest return on investment, streamlining bottlenecks without requiring workforce reductions. 

Best Practices: 

• Automate Processes with High Manual Load: This increases efficiency without affecting staffing. 
• Focus on Gaps: Automate areas that slow down workflows without requiring extensive restructuring. 

5. Streamlining the Revenue Cycle with Integrated Solutions

Integrating technology into electronic health record (EHR) systems enhances visibility, centralizes management, and reduces manual processes. A unified platform improves continuity across the revenue cycle, allowing staff to focus on delivering optimal care without system fragmentation.  

6. Continuous Education: Empowering Physicians and Staff

Ongoing training is vital in managing denials effectively. Both clinical and administrative staff need current knowledge on payer requirements, coding practices, and denial mitigation strategies. 

• Physician Training: Regular sessions help physicians understand the importance of accurate documentation and stay updated on policy changes. 
• Staff Education: Continuous training programs ensure that administrative staff can use AI tools efficiently and apply best practices. 

7. Aligning Clinical and Revenue Cycle Teams

Effective denial management requires a cohesive effort from clinical and revenue cycle teams. Synchronizing workflows and sharing information is crucial to avoiding denials. 

• Enhanced Communication: Regular communication between teams allows quick issue resolution. 
• Integrated Workflows: Aligning documentation with billing requirements streamlines processes and reduces error

8. Top Denials and Mitigation Strategies

Understanding common reasons for denials enables providers to address them proactively: 

• Prior Authorizations: AI tools can track authorization requirements, preventing delays. 
• Documentation Compliance: Prompt and accurate responses to documentation requests reduce denial risks. 
• Accurate Enrollment: Regular audits ensure that enrollment information is correct, minimizing claim rejections. 
• Eligibility Verification:

Conclusion 

Flipping your lens to focus on clarity over denials means adopting a strategic approach that leverages advanced technology, continuous education, and interdepartmental collaboration. By understanding payer strategies and employing robust denial mitigation practices, providers can transform denial management into an opportunity for streamlined operations and optimized reimbursement. 

References: 

1. “Setting the Revenue Cycle Up for Success in Automation and AI,” McKinsey & Company 

1. “Claim Denial Prediction: Harnessing AI For Healthcare Revenue Cycle Management,” Forbes 

Nio Querio, Nextech RCM Advisor, has 30+ years’ experience in Revenue Cycle Management for Manager Hospital Systems, PHOs, ASCs, Large Specialty Provider Groups and Primary Care Organizations. Nio was named as one of the Top 25 Innovators of 2021 by “Modern Healthcare.” She previously served as the SVP of Revenue Cycle at Tufts Medicine and currently serves as the Fractional Chief Strategy Officer at Nashville General Hospital.