Many specialty providers wrestle with denials. For example, ophthalmology practices have one of the highest denial rates—weighing in at nearly 13 percent. If left unaddressed, denials can translate to significant money, and the financial fallout for a practice can be severe. As mentioned in a previous blog, providers should consider creating a denials prevention program as a sound strategy for improving revenue cycle performance. Here are three elements to keep in mind when designing such a program.
- Shift to a more preemptive approach. Some of the most frequently occurring denials involve lack of patient insurance coverage, incorrect patient demographic information and insufficient medical necessity justification. One way to address these is to implement integrated electronic health record and practice management solutions, which are designed to reduce the likelihood of these denials. The technology improves registration accuracy, allows for efficient and effective insurance verification, and facilitates detailed documentation and coding. Note that practices can’t merely onboard technology and hope for the best, they must take a close look at their entire approach to patient access and coding to make sure that current processes support denial prevention.
- Employ data analytics. Health care providers have access to a lot of data around rejections and denials. By digging into this information and looking for trends, practices can often uncover issues that are repeatedly causing problems. Technology that facilitates data mining and analytics can be particularly helpful in this effort. By examining patterns, determining root causes and implementing strategies to mitigate issues, practices can limit the chances that the same kinds of denials will recur again and again. For example, if a provider notices a certain procedure is always denied, it can look at the reasons behind the denial and find ways to systemically correct the problem. This may involve providing education to improve coding, refining pre-authorization procedures to make them more consistent or pursuing strategies that ensure more accurate and comprehensive documentation.
- Automate processes on the back-end. Despite a commitment to prevention strategies, denials still occur, and providers must address them promptly. To effectively respond to denials, practices should consider using automated tools that streamline the appeals process. These systems can quickly pinpoint the reasons behind a rejection, generate customized appeal letters and seamlessly include relevant attachments, allowing the practice to communicate faster and more comprehensively with insurers, which will result in stronger recoupment and speedier cash flow.
Denials will always be a factor in a specialty provider’s financial operations. However, by shifting from reactive to proactive management strategies and leveraging technology to automate both the front- and back-end of the revenue cycle, specialty providers can reduce the number of denials and enable stronger revenue cycle performance.
To learn more about revenue cycle optimization, see our previous blog "Revenue Cycle Management 101: 3 Key Focus Areas" and "Three Strategies for Collecting Patient Payments" and keep an eye out for upcoming blogs in our RCM series that will dig deeper into related topics plus provide tips and actionable strategies to consider.