The keys to preventing and overturning payer denials are to collect data to identify problem areas and to train staff in best practices. The case management team should understand the information each payer wants and how best to share those data.
Claims denials have increased by 11% nationally since the onset of the COVID-19 pandemic, according to an analysis. Almost half of claims denials are caused by front-end revenue cycle issues, including registration/eligibility, authorization, or service not covered. Implementing a process to check eligibility at multiple points throughout the revenue cycle will go a long way in preventing this common denial from occurring.
Challenged with employing enough staff in case management departments, the need for expertise in every role, and the increased requirements from payers, case management leaders are evaluating centralizing utilization review. This centralization carries both benefits and challenges, some of which are amplified because of the current healthcare climate.
Inaccurate coding causes compliance issues, more denials, lost revenue, and negative patient experiences. More precise and accurate information from the onset sets the stage for correct billing, cleaner claims, and fewer denials.
Denied claims for urgent, medically necessary procedures are no laughing matter. Patient access staff have to appeal each denial, a time-consuming and expensive process. A New York law states that if a patient presents with unexpected complications or requires additional services in the course of treatment, a health insurer will no longer be able to deny payment due to lack of prior authorization.