……This Week in HealthCare

By Fred Binczewski | MHA fredb@uprisecg.com | Click Here to download this article (pdf).

January 20, 2022

Denials, Denials, and more Denials—When are they going to STOP!!!

In this issue of …This Week in HealthCare, we will discuss the synergy and ramifications of healthcare claim denials in all their glory and the ever revolving door through which they flow. Being mindful of their existence, we will search for solutions, opportunities and processes that bring them forward and upfront to the healthcare environment. We will also pinpoint some of the challenges that denials create and some of the preventive management that can occur to curtail and resolve the denial ever breathing enigma. This conversation will point to the governing management bodies and teams that will undo the claim denial trending and create a more positive workflow, happy patient billing and hence positive cash revenue.

Let’s begin by establishing a formal definition for claim denials as follows: “The refusal of an insurance company or carrier to honor a request by an individual, or his or her provider, to pay for healthcare services obtained from a healthcare professional.”[1] The cost of working and reversing denials has grown from the pre- covid years. Becker’s had the cost of working a denial at $115.00 each. It is my opinion that this cost has increased and possibly tripled by now for reasons that we are just beginning to understand. Organizational differences have led to politicized staffing requirements and guidelines for vaccinations based on the ability to work and report for duty. Staffing shortages created in these scenarios have led to doing more with less. With this comes the environment for more errors from all departments in a healthcare setting. The rise in covid patients taking up beds and maximizing required services has put an enormous pressure plate on staffing, operations and safety. We see the ramifications presently as some hospitals are no longer servicing unvaccinated covid patients. This has claim denials requiring more attention from less staff and hence the ability to keep up with timely filings, missing information, duplicate claims or service, coding errors and procedures not covered by payer. Easier said than done!

How do we get ourselves out of this predicament? The first step is to look at a denial from not a resolution basis, but from a preventative state process. Having PFS, (Patient Financial Services), send claims out only to get them denied is the process most organizations have been following. If staffing had a way to look at each patient cycle moment from all departmental views and a way to ascertain the significance of an error just made, then the opportunity to prevent this from cascading down the patient cycle would become the norm. This would prevent the majority of denials as we see them today.

The most significant solution for the creation of preventative measures lies in the education of staffing. Organizations talk about optimizing the revenue cycle, but if your staff and the front line workers are not educated in the processes and systems, optimization will not follow. Systems must be reviewed and held responsible. Example: Patient Access is always blamed for picking wrong plan numbers from insurance cards for registering patients. When an in depth analysis is taken, the results show that the insurance dictionary directory hasn’t been updated for years. Well well. In essence, education not only for staffing but a clean system will be an integral solution to the prevention of denials ever occurring. Finally, the covid environment as well as all the mutational variants that we are hearing about will require further implementation of preventative measures, not reactionary to help solve and minimize the effect of the denial rat race.

In closing, we at ….This Week in HealthCare and Uprise Consulting Group would like to thank all healthcare workers in this covid pandemic time even though some of the research suggests we are at a turn for the better.

Stay safe and diligent. See you all next time…….This Week in HealthCare

1. healthinsurance.org

To learn more about how we can help you with this topic or other healthcare questions please send us a message at the following: info@uprisecg.com

Uprise Consulting Group, Inc., Eliminating Denials Today, Tomorrow and into the Future.

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