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Denial management has been a thorn in the side of provider RCM teams forever.  And unfortunately, despite expanded EHR use and claim coding improvements, denial rates have continued to rise into the pandemic; from 9% in 2016 to 10.8% mid-pandemic in 2020.

Cost To Rework Claims

To make matters worse, the average cost of reworking denials ranges from $25-$118 per claim.  As a result, over 60% of denials are never resubmitted!  Here’s why:

  • Lack of A/R Specific Software: Payer and EHR variability has forced A/R into manual workflows
  • Staff Cost: Cost to retain skilled A/R follow up staff

Keys To Optimizing Denial Management

The good news is, modern software tools are easier to build and here to help provider billing teams.  Historically, only large hospitals and payers had access to the most advanced technology, but that’s changing rapidly.  Here are a few A/R follow up areas where modern software can help.

Auto-Triage of Claims

The current standard for all billing teams is to assess each claim one-by-one.  Typically, it’s an “ERA by ERA” assessment that often requires further digging to really determine the correct action.  However, payer claim decisions are pattern-based.  With modern tools that combine these patterns with your preferred triaging, the software can triage claims in batches.  This both removes the repetitive process of claim triage and optimizes the proper action decision.

100% Digital Appeals

Even after choosing to appeal a claim or send a medical record, the process of building an appeal letter, filling out a payer form, and then submitting it back to the various payers is extremely time consuming.  Some teams report that it takes 35 minutes per claim!

Finding the right language to best appeal the denial is challenging on its own.  What worked and what didn’t work — and why?  Billing agents are often left to themselves to figure this out.  From there, actually submitting the appeal via postal mail, fax, or payer portal is both time consuming, costly, and often requires a different team to touch the appeal.

Having a solution that turns this entire build and submission into a single, digital process for all denial types and payers is the only way to solve this major pain.

Team Performance Tracking

Without a digital A/R follow tool, described above, billing team managers are left to track their team’s performance through the use of onerous spreadsheets and difficult to assess reports.  Managers rely on their team members to train each other and report back any difficulties they might be experiencing.  This leads to real gaps in performance assessment and, ultimately, the ability to help their teams succeed.

Having a digital A/R solution fixes that.  The need for a real-time dashboard that provides these KPIs, along with real-time alerts related to individual agent performance, is the way forward.

Real-Time Denial Trends AND Alerts

Finally, as mentioned earlier, denials happen in patterns.  The challenge is, those patterns vary by payer, provider, region, and specialty.  And they change over time too!  So, these patterns are difficult to track manually.  Each pattern change has immediate downstream effects that can lead all the way back to the providers themselves, with annoying code corrections and medical records requests.

A modern A/R solution that is dedicated to sharing these patterns via a real-time dashboard is the key.  Not just a static dashboard with denial statistics, but in-app and email alerts that indicate an important change in a pattern.  That aspect is especially important, because all billing agents are extremely busy and are bogged down by task after task.  A smart platform that informs you of the most important information without any effort from you is required.

This is an exciting time for provider billing teams.  At DocVocate, our team is passionate about helping provider billing teams.  We’ve spent considerable time thoughtfully building our platform, Appealio, just for you.  New tools are on the way to help!

If you found this helpful and would like to discuss further, please feel free to reach out to us at info@docvocate.com.