Six Ways to Stop Claim Denials

Updated: Sep 29, 2022

With denials remaining a significant roadblock to full and timely reimbursement, and while denials occur across the revenue cycle, a high percentage are associated with eligibility, authorization and registration activities, all front-end processes.

Consider these sobering industry statistics:

Claim denials impact more than 3.3% of patient revenue
63% of denied claims are recoverable on first appeal (but are rarely appealed or reviewed for possible appeal)
Labor tied to the appeals process averages about $188 per claim

Below are six strategies to apply to decrease denials:

1. Determine Root Causes

Study data from the revenue cycle management process to spot where and when denials happen, making sure you know the data is trustworthy, timely, and accurate. Focus in on:

Inadequate documentation
Billing and coding mistakes
Patient registration errors
Case coordination/management
Past payer behavioral patterns

2. Install Business Rules on Quality

It is a good idea to update and maintain business rules to examine registration data for completeness, consistency and accuracy. An alert system identifying possible quality concerns will help identify and bring early resolution to any errors.

3. Review Priorities

Almost 24% of all US claim denials fall under eligibility and registration problems with services not covered accounting for 10%. This means eligibility must be checked throughout the treatment process.

One way to improve the eligibility verification process is with thorough training in point-of-service collections as well as insurance and preregistration for all front-line staff members.

4. Probe Medical Necessity and Prior Authorization

Precertification and authorization errors make up 18.2% of US claim denials. Again, studying the data will uncover the reason for authorization denials. Was it because of an expiration, an incorrect procedure or whether the information was even obtained.

The best preventive action is to obtain the authorization up front. Also, if the payer approves the procedure, additional changes on a scheduled procedure still could result in a denied claim meaning a double check of the authorization prior to the procedure may be a good practice.

5. Sharp Claims Processing

Prior to routing the claim to the payer, the practice needs to review it for errors and make the changes. Any edits are best made customized to the payer. Proactive visibility resolves issues so install a process to identify, submit and monitor claims.

6. Analyze the Revenue Cycle

Analyzing the cycle regularly is the key to improving the claim denial rate. Scrutiny is needed every step of the way to maximize the effectiveness of claim denial strategies.