Denial management is essential for any healthcare organization seeking to maximize reimbursements and optimize its revenue cycle. Unaddressed claim denials can result in substantial lost revenue for providers. For years, many healthcare providers have accepted claim denials as an unavoidable “cost of doing business.” But with rising operational costs and narrowing margins, unaddressed denials have become too expensive to ignore. Traditional denial management processes, once thought adequate, are now outdated and failing providers. It’s time for a wake-up call; the costs of inaction are too high.
Current denial methods struggle under the immense workload. As denial volumes grow exponentially, overburdened staff fall further behind. Claims sit untouched for weeks or months as specialists scramble to keep pace. Valuable reimbursements slip through the cracks as critical appeal windows close.
In a 2017 analysis, it was discovered that insurers on the Healthcare.gov marketplace denied almost 20% of claims for in-network services, as reported by KFF in 2019. The study also revealed that certain payers had an even higher denial rate, reaching as much as 45%.
Considering this let’s explore the challenges of traditional denial management approaches and discuss how adopting an AI-powered denial workflow solution can help providers proactively reduce denials and prevent future losses.
Challenges with Traditional Denial Management Methods
Traditionally, denial management has involved coordinating paper-based workflows across various departments. Coders, billers and follow-up specialists must pass denied claims back and forth as they research reasons for denial and pursue appeals or resubmissions. This process is inefficient, impacting turnaround times and allowing denials to slip through the cracks. Some key challenges include:
- Disjointed Workflows - Without a centralized system, it's easy for denied claims to get misplaced or important details lost in translation between teams. This leads to delays or claims not being properly addressed.
- Difficulty Tracking Trends - It's nearly impossible to analyze denial trends and identify issues proactively when using binders or spreadsheets. Current methods don't provide interactive reporting capabilities.
- Limited Customization - Paper-based systems offer little flexibility to modify workflows to address specific payer or regional nuances. Processes cannot be optimized based on evolving needs.
- Inconsistent Documentation - Notes may be handwritten or inconsistently captured, making it difficult for new specialists to pick up where others left off. Details are also at risk of being misinterpreted.
- Insufficient or Poor Documentation - Incomplete or unclear records can lead to claim denials due to coding errors, lack of prior authorization, or inaccurate billing information. Such deficiencies hinder the appeals process, making it challenging to rectify denials efficiently.
- Compliance Risks - Critical appeals or resubmission deadlines may be missed without an electronic auditing trail and automated follow-up notifications. This can result in even greater losses.
- Significant Labor Costs - Manual remediation is time-consuming, requiring dedicated FTEs to keep up with denial volumes. Labor expenses continue rising with workload increases.
As denial dollars pile up into the millions unrecovered each year, labor costs simultaneously eat away at margins. Current processes demand large FTE headcounts that continuously increase with workload growth. Recovering only pennies on each denied dollar means drowning in red ink.
To truly address this problem, a strategic shift to automation is imperative.
The Value of an AI-Powered Denial Management Solution
An AI-powered denial management workflow solution like that NDS InfoServ offers can help providers overcome traditional challenges and proactively reduce costs. By leveraging technologies such as machine learning and natural language processing, these platforms automate tedious manual tasks, scale workflows efficiently and provide unmatched visibility into denial trends. Some key advantages include:
Automatic Routing and Tracking
Denied claims can be automatically imported and routed to the appropriate work queues based on user-defined rules. This may involve routing to specific specialists based on payer, reason for denial, or other attributes. The online tracking ensures proper follow-up and accountability at each stage.
Customizable Staging
The solution allows providers to configure customizable workflow stages that match their unique processes. For example, stages can be set up for initial review, medical records requests, appeals preparation, secondary billing, and more. Key details are captured at each checkpoint.
Root Cause Analysis
Providers can leverage interactive dashboards and charts to analyze denial trends across payers, reason codes, providers, procedures, etc. This delivers actionable insights into underlying drivers of denials to focus remediation efforts.
Prioritization of Top Denials
Administrators can prioritize the top denials for recovery based on filters like dollars at risk.
Specialists can then directly work on these high-impact cases within optimized online work lists.
5. Side-by-Side Claim and EOB Comparison
Review of denied claims alongside original claim details streamlines analysis and decision making. Discrepancies are easily spotted to determine appropriate next steps.
By automating these specialized denial management workflows, healthcare organizations can scale their processes more efficiently to maximize revenue recovery and proactively reduce future risks.
A Winning Proposition for Revenue Cycle Leaders
Persistent denial rates are eroding your margins. Current processes lack the finesse to optimize reimbursements in turbulent industries. It's time to take control of your financial destiny. NDS InfoServ's AI ensures proactive revenue management with scalable visibility. Granular insight empowers data-driven countermeasures. Continuous machine learning future-proofs operations, delivering immediate ROI through efficient workflows. Seize financial security by embracing optimized intelligence. In today's reimbursement landscape, unaddressed denials pose a substantial risk. Traditional manual methods exacerbate issues. Integrated AI platforms are the decisive way forward for denial management success.
