In 2020-21, hospital claim denial rates reached a new high. The pandemic has accelerated the trend of claim denials, with a more than 20% increase in the past two years. Healthcare providers must continue to improve their claims management skills to prevent this trend from getting worse. Healthcare Billing is especially true at a time when the virus manifests itself in many ways and is likely to keep the industry on its feet for a while. We will discuss these trends and offer ways to combat them in this blog.

Healthcare Billing

Here are the Top 20 Denial Reasons for 2021 and How to Control Them.

Errors in Front-End Processing

According to a recent stat, 89% of hospitals have seen an increase in claims denials over the last three years. A similar stat shows that 51 percent of hospitals have seen a significant rise in claim denials. The commonality in claims denial is a problem in the front-end revenue cycle management. Experts believe that the best way to control denial management is to manage the front end more effectively. This is primarily possible by:

Early detection of errors such as missing or invalid claim information is key. Denials can be eliminated by “scrubbing” claims-required information at the beginning. Easy onboarding and education of new customers are key to reducing errors at the front end. An easy onboarding process means a simple billing manual with Medcare (MSO) Medical Billing Services. 

Establishing metrics to identify customers/departments/employees with the highest rate of errors (incorrect or missing demographics, coding, insurance, etc.) on claims. Over the past two decades, the success rate of claim denial appeals to private payers has fallen from a median of 56 percent to 45 percent. It’s possible to avoid denials in the first place.

Denying claims is difficult because most of them can be avoided. According to a recent statistic, nearly 46 percent of claim denials can be avoided. Your first priority as a provider should be to eliminate what is not possible. This is best done by utilizing innovative solutions available to automate the front end of the revenue cycle such as registration, eligibility, and verification.

Analytics can be used to develop a denial prevention strategy. This will allow you to pinpoint the source of denials and create a strong mitigation strategy. Experienced available to supervise medical necessity, eligibility, registration, verification, preauthorizations, and medical coding. They can also assist with missing claims or services not covered. Most commonly, a prior authorization request will be denied if the requested medical service/medication is not evidence-based.

Writing off denial

• Over the past few years, denial write-offs for medical necessity have been increasing. This is where an organization “writes off” revenue because it is not recoverable after unsuccessful appeals and appeals.
• It is important to have a clearly defined process for eligibility verification and preauthorization. Automating the initial round can improve accuracy and speed up the process.
• Manual handling is best handled by two teams.
• A well-structured payment posting process is essential to enable patient follow-up teams to do timely follow-ups on money recovered from patients.

Losing Out On Denial Appeals

The success rate of claim denial appeals by private payers has dropped dramatically in the past few years. Claim denial appeals can be appealed by hospitals to reconsider rejected cases on the basis of correct evidence. To avoid being part of this trend, the best way is:

• A special appeal staff should be identified by the payer. This allows you to gain a better understanding of specific payer requirements and helps you to cite contract terms.
• Requests should be submitted in writing using the payer-specific appeal templates. Include all components and have them viewed by experts.
• All departments should be involved in the appeals process. There are many other teams involved, including pre-authorization, clinical documentation, and clinicians. You can contribute to a successful appeal.
• The appeals for Medicare Advantage and Medicare denials by providers were more successful. This number grew from 50% to 64%.

Denials Due To Coding Errors

Incorrect coding was a major reason for many denials. According to the survey, 32% of respondents cited coding as their top concern. This is an area of the revenue cycle that requires constant attention to spot problems with coding before they occur.

• A healthy mix of certified and experienced coders puts experienced coders in charge.
• To ensure that they stay current with the latest changes in code, trainers use both online and software resources.
• A multi-level quality control system to examine every bill for any coding issues. also a perfect record of all errors.

Refusal to File in Time

Healthcare providers often face the problem of claims being denied due to late filing. Because each insurance carrier follows its own guidelines, it can be confusing. Resubmissions can be slow after an analysis of a claim, which could lead to missing the deadline. Avoid filing claims late by following these steps:

• Each player will have a dedicated team of billers. This allows for specific attention to each payer as well as keeping up-to-date on specific payer requirements.
• Prioritizing claims and resubmissions based upon criticality, value, and others. A proper tracking system can streamline submissions and help speed up the process.

Flexibility can make a huge difference.

In the coming year, managing denials will be a difficult task. It is therefore essential to develop a strategy for dealing with denials in the future. It is essential to devise a strategy that minimizes denial by taking proactive steps. This will allow you to manage denials effectively by identifying and rectifying denials, analyzing them, and managing payer contracts.

A three-prong strategy is ideal for every provider. First, stop claims from being denied. Audit and analyze denial data to identify the source of errors. Providers can get a clear picture of the situation by analyzing and grouping them according to the payer, type of denial, reason, and the number of errors per type. Providers must draw and revise their improvement targets based on this constantly changing picture.

Who are we and what makes us experts?

The source of the Healthcare Billing article is Medcare (MSO), Medical Billing Services. They are a BPO provider that specializes in denial management and a variety of back-office support services. Our dedicated staff is experts in medical denial management. They keep up-to-date with payer rules and fine-tune their checklist to ensure timely and correct claims submission. We have helped our clients promptly review their audit and denial data and maintain regular communication with payers to ensure reimbursements are timely. For more information, get in touch with one of our experts.