Leveraging a Rules-Based Engine for Touchless Denial Management
When it comes to handling denials, one of the most significant burdens on practices is continuously changing payer requirements. Between March 2020 and March 2022, there were more than 100,000 changes to payer requirements for processes related to coding and reimbursement.1 The time it takes to stay on top of these changes and gather supportive documentation to create the appeal requires a high degree of expertise and hours of investigation.
Conducting numerous payer calls, obtaining and completing corrected forms, and monitoring appeal statuses can be especially difficult for practices experiencing staff shortages or turnover. This is why many practices choose to rework only the highest-value denials, leaving much-needed smaller amounts on the table—amounts that can add up over the course of a year.
Denial Prevention
Of course, the best way to avoid the financial impact of denials is to prevent them on the front end. Tools like claim-scrubbing technology can help. These solutions completed edits of diagnosis codes, medical necessity, procedures, file formats, and more to ensure claims are correct prior to submission.2
Code check software and encoders save time and money by upping the accuracy and efficiency of codes with one-click validation.3
Medical scrubbers also help by ensuring claims are compliant with coding standards. These tools work by automatically matching diagnosis codes with the correct CPT/HCPCS codes. According to the Journal of AHIMA, “Code check software and encoders save time and money by upping the accuracy and efficiency of codes with one-click validation.”3
Yet, even with these tools, there will always be a certain percentage of denials that happen due to a variety of issues, some of which are beyond a practice’s control. Fortunately, there is now a way to automate denial management on the back end so denials can be processed without human intervention.
A Hands-Off Approach
“Touchless” denial management is now a reality thanks to technology that leverages rules-based engines. A rules-based engine operates on “if-then” statements and is a great tool to use for processes where information is highly complex and changes often, such as payer requirements.
“Touchless” denial management is now a reality thanks to technology that leverages rules-based engines.
In healthcare, rules-based engines are able to automate much of the traditional back-end denial management workflow. By identifying root causes based on payer denial codes, the technology can automatically route the denial through the appropriate appeal process. This can be especially effective for managing bulk denials from a single payer.
Another great example of the benefits of a rules-based engine is its ability to streamline secondary insurance denials. The technology can identify when a secondary payer is available and then automatically transfer the balances to the next appropriate payer. This process is entirely automated using a built-in coverage discovery capability. In this way, the denial can be managed without ever being touched by staff.
Rules-based engines can also provide in-depth insight through root-cause analysis that helps identify more systemic patterns. Having this insight can help practices implement solutions to improve processes and prevent denials in the future. The insight gleaned can also be helpful in more effectively managing contractual adjustments and write-offs.
The Bottom Line
Implementing technology like rules-based engines can significantly impact a practice’s ability to be reimbursed on time and in full by automating denials management on the back end. However, many practices lack the resources to purchase and implement such technology. For these practices, the next best option is to partner with revenue cycle experts who have the technology already in place. Conifer Health is a great choice.
Conifer leverages its rules-based engine to automate back-end denials management workflows, removing the need for human intervention. Practices benefit from faster appeals, a greater number of appeal approvals, and more timely reimbursement while also alleviating stress on existing staff.
References
- https://www.experian.com/healthcare/resources-insights/thought-leadership/white-papers-insights/state-claims-report
- https://journal.ahima.org/page/claims-denials-a-step-by-step-approach-to-resolution
- https://journal.ahima.org/page/claims-denials-a-step-by-step-approach-to-resolution