UNCOMFORTABLE FACTS...
Health system CFOs have listed the top issues confronting them. This is Part 3 of a four-part series exploring these issues and solutions.

CURRENT ENVIRONMENT

• 90% of claim denials are preventable.

• 65% of claim denials are never corrected and re-submitted.

• Denial Write-Offs to Uncollectable has increased by 90% over six years ago. (2017 Advisory Board Survey)

• Since 2015 successful appeal averages have fallen nearly 20% for Commercial and Medicaid payers.

SOLUTIONS

1. Correct Mistakes at Registration

• Validate all of a patient’s information each time they are registered.✓

• Verify all applicable fields are populated, current and correct.

• Don’t rely on previous registrations even on well-known patients; information changes.

 

2. Ensure Patient Eligibility

• Verify with the payer that every patient is eligible to receive all scheduled services.

• Use any combination of tools including phone and web-based portals or consider outsourcing this function to save personnel costs.

3. Ensure Preauthorization

• Verify all services are pre-authorized. Industry best practice minimum threshold is >98%

• Create a master list of your payers and their requirements in an easy-to-access format making special note of any services that require pre-authorization.

4. Correct Coding Errors

• Consistently maintain updates in coding tool and systems.

• Ensure selected codes accurately describe services performed.

5.  Provide Sufficient Documentation

• Diagnostic testing documentation and treatment notes must support coding.

6. Establish Medical Necessity

• Poor documentation and insufficient coding lead to medical necessity denials, which are a very easy way for payers to deny claims.

• Improving the quality and accuracy of documentation and coding will decrease these denials.

Implementing these steps will help patients and hospitals focus on care, not payment.