Beat the Endless Cycle of Claim Submission, Denial and Resubmission

COVID-19 has toppled healthcare provider revenue cycles and, according to an American Hospital Association (AHA) report, hospitals lost more than $50 billion a month from March 1 to June 30, 2020.

Slow reimbursements and poor cash flow — due to outdated, largely manual revenue cycle management (RCM) operations — are placing an increased financial strain on most healthcare providers. And claim denials have an even higher price tag.

According to the Medical Group Management Association (MGMA), the average cost for each reworked/appealed claim is $25.10. Reworking claims also derails efforts to improve patient care. In a recent Healthcare Information and Management Systems Society (HIMSS) survey, 76 percent of healthcare leaders acknowledge that claim denials are their greatest challenge.

Why do providers struggle with repetitive denials and resubmissions? Most denials have clear process instructions from the practice for claim resubmission, so unless denials are worked based on defined process instructions, the claim will be denied again. Usually, accuracy of working claim denials depends on human memory, making the work susceptible to error.

For example, while processing the claim denials, the payers may have denied the CPT 64405 as “Medically Not Necessary” and it was advised that the remaining amount be borne by the patient in the EOB. So, the balance must be transferred to the patient and no appeal should be submitted as the payer does not cover this service.

Pain relief for repetitive claim denials
To solve the issue of claim denials, you need a process-driven Workflow Management Solution that works: first, it should organize updates and instructions from disparate sources — such as email, phone calls and meeting notes — in a central repository for easy access and reference. The instructions should then be transitioned into a structured template, and each instruction should be tagged to a specific naming format for future reference, enabling integration of workflows with process knowledge instructions.

Implementation of structured rules means updates are well organized and stored in a centralized tool/portal enabling efficient claims resolution. And integrating the structured process updates with workflow management enables the system to prompt staff with specific instructions to efficiently address AR. It is also a good idea to integrate the knowledge management tool and the workflow engine so that it lays the groundwork for a disruptive amalgamation of process instructions with your practice management system to automate AR resolution in the future.

Employing this solution would ensure an efficient resolution of claims and optimized AR resolution, resulting in improved cash flow.

NTT DATA has created a process to embed process instructions onto the workflow tool as part of a process-driven, (rather than people-driven) solution. Our solution enables staff to work denials accurately, based on pre-defined process instructions. This dramatically increases the likelihood of payment upon first resubmission instead of having the same claim denied again and reworked multiple times.

Resolve claims in a more efficient way. Learn how we helped ALN transform its claims processing workflows to drive continued business success.

Connect with us at bpo@nttdata.com or visit our site to experience the benefits of improved cash flow and reduced AR.