A hospital’s denial issues vary based on the organization, and because of this, sometimes pinpointing potential denials can be difficult.
Moving from a management to a prevention model is a slow process, and issues can potentially arise if denials by the department are overlooked. However, the point of denial prevention is to move towards a denial-free workflow even if it isn’t immediately possible.
Studies show that if a claim denies once, there is a 60% chance that the same claim will deny again. For organizations looking to lower this percentage and increase their number of clean claims while working towards prevention, they should pinpoint areas causing denials and shore up internal processes to decrease them.
After a denial occurs, two questions should be asked:
- Was this denial preventable, and
- How can we adjust our processes to combat future denials?
These questions should guide the rest of the denial process.
Let’s look at some different hospital denials by department and their potential solutions.
Patient Access
Patient access is typically the first point of contact that patients have with a hospital. This initial contact is a chance for the hospital to prevent denials from the beginning of a patient encounter. In scheduling, failure to obtain prior authorization or pre-certification and not capturing accurate patient data are significant contributors to denials.
Patient access departments can solve this by ensuring their staff is familiar with payer contract requirements and scheduling non-emergency services in advance to allow time to obtain prior authorization and validate medical necessity.
Pre-Registration & Registration
Pre-registration and registration have very similar denial tendencies to each other. Not obtaining pre-certification and non-covered services are significant issues during these processes.
Double-check that insurance information is complete, patient demographics are validated, and line item verification has been performed to combat these issues. Confirm your staff is trained to recognize complete orders and that your registrar is focused on financial clearance.
Ancillary Services
Ancillary services denials can become complicated because several services operate simultaneously. Still, the most common denials in this department are medically unnecessary services and failure to obtain the necessary authorization.
Staff education is the best course of action to combat these denials. Your staff should be informed about National and Local Coverage Determinations and trained to issue ABNs.
Health Information Management
The primary issues in most H.I.M. departments are coding discrepancies and medical records being submitted late. To solve these issues, records should be coded promptly, and the coding quality needs to be validated.
Contact physicians with questions about unclear or missing documentation and remove incorrect charges. Most of these tasks are laborious but can be solved with appropriate technology.
Patient Accounting
Patient accounting issues are usually Chargemaster related. The issues can also be untimely filing or incorrect codes/edits in the claims scrubber; thankfully, most of these issues can be solved through maintenance and education.
Chargemasters should be audited regularly, and contact management software should be kept up-to-date. Staying on top of both of these will help ensure that denied claims get appealed and that rejected claims are corrected accurately and quickly.
Information Systems
Issues within information systems are generally related to interface issues or inadequate reporting. Recent and updated technology is vastly important here, ensuring all systems are updated, ad-hoc reports are audited, and that all denial data has been extracted and collected electronically. Adequate technology is one of the most important aspects in creating a denial prevention framework.
How TREND Can Help
TREND Health Partners provides strategic business intelligence reporting through TREND’s Optics reporting platform. Optics gives clients access to valuable, real-time reporting based on previously disparate denial management data. Create intuitive dashboards with Optics’ flexible framework to display insightful information and pave the way to discovering actionable data points to improve denial management and denial prevention programs.
CAVO’s AI-supported medical record review platform extracts critical clinical attributes from the patient’s medical record to efficiently present to the clinician to support an accurate determination within minutes. This intelligent automation capability leads to automated approval and streamlines the process for any required clinical review. The intuitive interface removes conventional friction and increases transparency and efficiency, creating a member-centric, consumerism approach. Harnessing the power of CAVO, our proprietary conversion, classification, and clinical extraction capabilities enable a clinical review process that is 10-15 times faster than traditional methods.
Get in touch below to discuss how TREND can make an impact on your organization.