Navigating denials is a critical part of the revenue cycle management process for hospitals, health systems, and physician groups. As payer reimbursement processes become increasingly complex, it’s essential to have a comprehensive strategy for preventing denials and effectively managing appeals. Building better relationships with payers should be a part of that strategy. This blog provides proven ways to better navigate denials and mitigate their impact.

Preventing Denials

As payer denials continue to rise, it is essential that providers stay on top of increasingly complex payer requirements, especially those regarding coding, prior authorization, timely filing, and appeals processes. The challenge here is that staying abreast of these requirements can be a full-time job. One option is to assign that responsibility to specific staff members. When no one owns a process, that process often goes overlooked.

Another key to preventing denials is to look for ways to automate manual, error-prone patient access processes since the majority of denials happen here. Missing or incorrect eligibility information are top reasons claims are denied. Automation technology can reduce manual processes like calling payers or searching payer websites for coverage information. This gives already overburdened staff more time to focus on patients or other strategic initiatives while also improving productivity and claims accuracy.

Of course, to prevent denials, providers must understand what’s causing them in the first place. Revenue cycle management solutions can perform root cause analysis, providing real-time visibility into problematic trends and issues that lead to denials. Armed with these insights, providers have the information they need to proactively address issues before they have a chance to impact revenue. For example, if many denials are due to coding errors, providers may want to consider additional training or certification for the billing staff. Likewise, if a large portion of denials occurs with a single payer, providers may want to thoroughly review that payer’s contract to ensure both they and the payer are following the agreed-upon contract details.

Appealing Denials

The denial appeals process is time-consuming and resource intensive. This is why many provider organizations work only the highest-value denials. While understandable, this approach leaves money on the table. And that money adds up over the year. A better approach is to use technology to automate as much of the appeals process as possible so more denials can be successfully appealed faster and with fewer resources.

The best solutions access information in the EMR to identify issues like missing information, coverage or eligibility problems, and coding errors. Some can also identify noncompliance with payer requirements, such as timely filing or prior authorization. By automating this part of the appeals process, staff can spend less time searching for information and more time creating the appeal. Many solutions also provide a library of prepopulated appeals letters, which makes submitting the appeal more efficient.

Building Better Payer Relationships

The friction between payers and providers can make these relationships challenging to develop and maintain. But doing so is essential not only for accurate, timely reimbursement but also for reducing delays in care and creating positive patient experiences. For example, when issues with prior authorization occur, patients can go weeks or months without the care they need. This can negatively impact outcomes and patient satisfaction.

One option for building better payer relationships is to have certain individuals become experts on specific payers. This person should regularly review the payer’s contract to ensure the specifics of the contract are still aligned with the provider’s revenue cycle strategy. If not, renegotiating the contract may be necessary. Scheduling regular monthly meetings with payers is also beneficial. These meetings can be used to discuss issues and proactively identify issues.