Many hospitals are facing a growing challenge of having their claims denied by payers, which can negatively affect their revenue cycle and cash flow. According to a recent analysis, the average denial rate for hospitals has increased by more than 20 percent in the last five years, reaching as high as 15 percent for some facilities. However, not all denied claims are lost causes. In fact, research shows that up to two-thirds of rejected claims can be successfully appealed and reimbursed if hospitals follow the best practices for claim management and resolution.
One of the main reasons for the rise in denial rates is the increasing complexity and variability of payer policies and requirements. Hospitals have to deal with different rules and criteria for different payers, plans, and services, which can lead to errors and discrepancies in coding, documentation, and authorization. Moreover, some payers may change their policies frequently or without notice, making it hard for hospitals to keep up with the latest updates and expectations.
To reduce the risk of denials, hospitals need to invest in proactive and preventive strategies that can ensure the accuracy and completeness of their claims before submission. This may include implementing automated tools and systems that can verify eligibility, validate codes, flag potential errors, and generate alerts for missing or incomplete information. Additionally, hospitals need to train and educate their staff on the best practices and standards for coding, documentation, and authorization, as well as the specific requirements and guidelines of different payers.
Even with these preventive measures, some denials may still occur due to various reasons such as payer errors, technical glitches, or disputes over medical necessity or coverage. In these cases, hospitals need to have an effective and efficient process for appealing and resolving denied claims. This may involve assigning dedicated staff or teams to handle denials, tracking and analyzing the root causes and patterns of denials, prioritizing the most valuable or time-sensitive claims, and following up with payers regularly until a resolution is reached. e0e6b7cb5c