Recover Payer Revenue By Addressing Front End Claim Denials

Keep reading to learn how day-to-day workflows are actually costing your practice money.

With inflation at an all time high, every business is taking a hard look at where and how they’re spending money. Coming off the heels of a pandemic, every area of the consumer sector is experiencing the effect of exponentially soaring prices, on a daily basis. The healthcare industry is not exempt from this either. Patients and providers alike are feeling the impact of clinical & non-clinical staffing shortages, care accessibility, and supply chain issues. However, in healthcare the shift to address these challenges rarely happen in real-time or at best, in enough time to prevent a decline in revenue. According to a McKinsey survey, many healthcare leaders anticipate a decline in operating margins due to this cycle of inflation, and subsequently, significant, negative impact on growth.

Start at the beginning

So it also makes sense that healthcare providers are watching their bottom line and making more intentional choices about where to spend money. Many healthcare providers will look for cost efficiencies through workforce reductions, others by employing automated processes, or reducing services. The first step though is to take stock of the current landscape and plug some of the holes in the existing process. Starting by managing front end claim denials.

Most Common Claim Denial Reasons for Physician-Based Practices

  • Timely filing
  • Eligibility denials – invalid subscriber ID, inaccurate patient information, missing patient information
  • Prior authorization – Pre-certification or authorization not obtained, insufficient medical necessity
  • Non-covered services
  • Coding issues – bundled services, incorrect use of modifiers, upcoding, coding incomplete, duplicate claim, improper modifier use
  • Data discrepancies – claim errors, missing or invalid claims data, missing documentation, inconsistent data

Get ahead of the curve

These denials listed above show an ongoing trend that hasn’t changed much in the last 7-10 years. They are basic adjudication edits related to verification & coding. The majority of these are front end claim denials that incorrectly end up in the appeals area, and aren’t eligible for detailed review or overturn unless there is clear, supporting documentation disproving the denial. Even if you’re in a position to renegotiate the reimbursement rates in your provider contract this year, start by addressing the front end denials. Review your current office procedures to pinpoint the actions that are creating these denials, address that, then set processes in place to identify discrepancies before the claim is filed. This small step will provide the opportunity to get paid the first time and avoid the expense of having to rework the claims.

90% of front end claim denials are preventable

  • Confirm benefits, benefit limits, financial responsibility, authorization & referral requirements prior to the patient’s visit.
  • Verify that claims are accurate and complete before submitting
  • Conduct a quarterly review of your chargemaster or claims management software for edits or updates
  • Make a list of each payer’s rules for claim submission, be sure to also include timeframes & guidelines for dispute resolution

Servicing

  • Combine like concerns – Group denials by payer, then by denial, and work in batches.
  • Use the payer’s portal when possible, particularly in instances where the payer incorrectly applied the denial.
  • Review current desk procedures to catch potential front end claim errors as most front end denials are not eligible for appeal.
  • Also take note of how often claims need to be reworked for coding problems and develop processes to catch the potential errors prior to initial submission.

Lessons Learned – Moving Forward

  • For any given timeframe, front-end denials should account for 10% or less of the total denial rate
  • Implement processes to catch discrepancies before claims are filed
  • Take the time to read the provider communications that the payer sends to stay ahead of procedural changes

When looking for ways to save or recover hidden dollars, address the variables within your control first. Keeping your front-end denials to a minimum is an effective, simple way to not only be proactive, but efficient and it’s the easiest way to get payer revenue the first time around.

Make 2023 the year you maximize reimbursement from your contracted payers. Join me on Thursday, 1/19/23 at 11:30 a.m. EST, I’ll show you the 5 Steps to Drive Payer Revenue. Register here. Be sure to invite your colleagues, business partners, and clients so they can stop leaving money on the table too!