The Executive Suite: Your revenue cycle’s worst nightmare: Optimizing denials management, recover revenue

In the complex landscape of healthcare revenue cycle management (RCM), the challenge of managing denied claims looms large. Insufficient resources, staffing, and limited bandwidth often contribute to complications in addressing denied claims, with an alarming 82% to 90% of denials deemed potentially avoidable. RCM teams can save time and recover revenue by utilizing proactive measures and technological solutions to navigate this difficult terrain.

Lack of proper resources and staffing contribute to complications in denials management

With a staggering rate of denials deemed potentially avoidable, it raises the question of why so many are slipping through the cracks. Insufficient resources stand out as one significant challenge. Managing denials can be an intricate and involved process that often requires pulling in people outside of the RCM team. Clinicians can provide insight as to why a patient requires certain items or services, but the logistics of coordinating information between teams to appeal a denial can be challenging. Trying to track denials without claim data analysis tools can leave staff with no visibility into approaching filing deadlines, resulting in denials lost.

In addition to staffing complications, the financial implications of appealing denials also play a role in proper management. Appealing each denial can be a hefty expense, with a single appeal costing anywhere from $25 for practices to $181 for hospitals. With these factors at play, having insight into how successful your team is in managing claims is essential, a task that is nearly impossible to track without the use of a software system. Though tracking claims manually with spreadsheets or working through an electronic medical record (EMR) may initially seem cost-effective, this can end up costing more in stress, increased time investment, and lost revenue. Investing in the proper tools and technology is imperative for effective denial management.

Limited bandwidth for managing denials

Another set of challenges RCM teams face stems from limited bandwidth for addressing claims effectively. One silent killer of efficient management is timely filing, requiring vigilant monitoring to ensure that crucial deadlines don’t fall off the radar. This impact extends beyond denials, posing a significant risk of lost revenue. According to the Council for Affordable Quality Healthcare, the process of manually checking statuses for unpaid claims alone takes a lengthy 14 minutes per claim. When factoring in additional tasks required for follow-up, the number of staff hours needed can be significant. Over time, this accumulation becomes a burden that can spiral into an unmanageable workload. Given the current staffing shortages, it becomes increasingly unlikely that health organizations can allocate the necessary time to research the root cause of denials, effectively manage and appeal denied claims, and diligently track down the status of unpaid claims. The challenges of limited bandwidth and the intricacies of managing denials emphasize the need for a streamlined process and sound technological solution to optimize revenue.

Streamlining analysis and workflow to improve denials management

Enhancing denials management calls for a strategic approach centered around streamlining analysis and workflow. The first step in reducing denials involves identifying the root cause, with registration/eligibility emerging as the leading contributor, accounting for 22% of claim denials in practices. Leveraging the information that practices have readily available is crucial in identifying necessary changes and implementing procedures to prevent future denials. Utilizing software to automatically generate reports and analyze trends and outliers eliminates the time-consuming legwork of manually compiling this information, allowing staff to focus on higher-value tasks. Efficiency is paramount in successfully managing denials, and team collaboration to establish priorities can significantly streamline workflow, ensuring no details are overlooked. Software platforms that incorporate features like productivity dashboards can be instrumental for teams, providing a central location for tracking individual and group progress. This holistic approach, integrating technology and collaboration, facilitates a proactive strategy for managing denials and optimizing workflow.

Setting your team up for success

In the health industry’s current state, marked by high turnover rates and understaffing, it’s important to set teams up for success and support new employees by formalizing learning materials and training procedures. This ensures new team members consistently adhere to best practices and lays out clear, comprehensive company guidelines. Most RCM leaders report that hiring and training stand out as top a struggle, posing significant challenges for their organizations. This challenge is a leading contributor as to why a staggering 65% of denied claims go unworked. To address this issue, it becomes imperative to guide new team members on how to effectively process denials by providing valuable resources, such as examples of specific denial types and documented best practices for efficient follow-up. By establishing a structured and comprehensive onboarding process, RCM teams can enhance their ability to navigate the complex process of managing denials, mitigate the impact of staff turnover, and ultimately improve the success rate in claims processing.

Managing denied claims is one of the biggest headaches RCM leaders face. Utilizing software platforms empowers teams to streamline workflow and improve management in the face of unique challenges posed by the industry. This technology allows companies to analyze trends for a clear picture to identify where revenue is being lost, and effectively integrate with a company’s EMR to save not only time but also the headache of individually managing denials and keeping up with deadlines.