And how we can help you clear each one
10 Hurdles to Fast, Accurate Reimbursement
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The average denial rate is up 3% since 2016, hitting 12% of claims denied upon initial submission in 2022. Leverage insights from our 2022 Revenue Cycle Denials Index to reduce your denial rates:
See the hurdles
Denials Continue to Rise Despite Providers’ Exhaustive Efforts
What are your highest hurdles to fast, accurate reimbursement? See how we can help you clear each one.
Nearly half of denials are occurring in front-end processes. Start here to help gain control of the problem.
Of the almost 31% of denials that are unequivocally avoidable, 43% cannot be recovered. Prevention is the key to avert revenue loss.
With RCM Complete™, Change Healthcare’s portfolio of revenue cycle solutions and services, you can address most any denial issue you’re facing.
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The Change Healthcare 2022 Revenue Cycle Denials Index Change Healthcare internal data, 2016-2022 *Percentages have been rounded
Select below to see how we can help you clear each one.
What are your highest hurdles to fast, accurate reimbursement?
Ensuring Accurate Registration
Verifying Eligibility Consistently
2
Completing Timely Authorization/ Pre-certification
3
Demonstrating Medical Necessity
4
Sending Attachments Efficiently
5
Coding Claims Accurately
6
Avoiding “Missing or Invalid Claims Data” Denials
7
Ensuring Timely Filing
8
Efficiently Responding to Denials that Occur
9
Using Data to Drive Decisions
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• Manual workflows are error-prone. • Patient-supplied info isn’t always reliable. • Automatic data-quality checks aren’t in place.
ensuring accurate registration
Hurdle #1:
A seemingly simple process often causes denials
Clear this hurdle
• Manual workflows are error-prone • Patient-supplied info isn’t always reliable • Automatic data-quality checks aren’t in place
Leverage technology to catch errors early and avoid denials down the line
Improve Accuracy With Real-time Data and Automated Quality Checks
Send error warnings to alert registrars to correct issues immediately. Verify patients’ demographic data quickly. Identify missed coverage. Reduce the need for manual registration audits. Flag potential fraud or identity theft. Integrate analytics to determine the root causes of denials and process improvement opportunities.
Spot potential errors fast
Clearance helps:
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Automatically checking registration information for accuracy and completeness highlights concerning areas for staff to address directly with patients. Customizable business rules let you tie to any field in the registration record to check for errors, including insurance plans, patient types, financial classes, and more. Programs are integrated with the U.S. Postal Service database, so you can verify address accuracy and standardize data formats to keep your data clean.
Integrate analytics to determine the root causes of denials and process improvement opportunities. Spot potential errors fast. Send error warnings to alert registrars to correct issues immediately. Verify patients’ demographic data quickly. Identify missed coverage. Reduce the need for manual registration audits. Flag potential fraud or identity theft.
Quality-check registration information automatically
Address service-coverage issues by flagging patients seeking a non-covered issue due to:
• Inaccurate coordination of benefits. • Lack of visibility into a patient’s benefit maximum. • Inconsistent coverage verification.
verifying eligibility consistently
Hurdle #2:
22% of denials originate in registration/ eligibility due to
1. The Change Healthcare 2022 Revenue Cycle Denials Index
• Inaccurate coordination of benefits • Lack of visibility into a patient’s benefit maximum • Inconsistent coverage verification
The more predictable the eligibility verification process, the less chance of error
Bolster Process Consistency, Reliability, and Timeliness with Technology
Manage nuanced eligibility denials and leverage those analytics to identify root causes.
Ensure you’re using up-to-date patient benefits information. Convey the patient’s coverage quickly with standardized payer-response screens (e.g., an “HMO” flag appears on the system dashboard when a patient has an Advantage plan).
The benefit maximum already being reached. Coverage not extending to the service type. Lack of medical necessity. Other issues.
This allows your staff to work with the patient on secondary coverage, generate ABNs for non-coverage automatically, and connect the patient with financial services for payment options.
Medicaid Insight is only available as part of the Coverage Insight™ solution. Coverage Insight™ helps identify sources of coverage for patients presenting as self-pay to help maximize reimbursement for services, improve patient satisfaction, and reduce the risk of bad debt. This solution is best suited for mid-to-large sized hospitals (200+ beds).
3.
Identify undisclosed coverage
Bill the correct payer the first time. Reduce denials attributed to the coordination of benefits. Obtain maximum reimbursement.
Our module’s insight helps identify existing commercial coverage that should be billed prior to Medicaid to help you:
Connect with 1000+ payers to verify eligibility
Our module’s insight helps identify existing commercial coverage that should be billed prior to Medicaid to help you bill the correct payer the first time, reduce denials attributed to the coordination of benefits, and obtain maximum reimbursement. Manage nuanced eligibility denials and leverage those analytics to identify root causes. Identify undisclosed coverage.
Inconsistencies due to process complexity and changing payer requirements. Poor collaboration between revenue cycle and clinical staff.
completing timely authorization/pre-certification
Hurdle #3:
13% of denials stem from pre-authorization issues
• •
2. The Change Healthcare 2022 Revenue Cycle Denials Index
Automate processes and stay current on changing payer requirements
Improve Pre-authorization Consistency and Timeliness with Technology and Expert Insight
Enable faster pre-authorization for complex requests. Transmit an authorization request directly to a payer from the existing workflow and automatically include an InterQual® medical review. Receive instant authorization for most requests if the review meets payer criteria.
Automate pre-authorizations requiring a medical review
Automatically determines if a pre-authorization is required and on file. Monitors payers for pending decisions and posts updates in your HIS. Displays payer decisions, including approval and authorization number. Alerts staff to a denied request by displaying a denied status code.
Clearance Patient Access Suite reveals the status of pre-authorizations in real time:
Improve visibility into pre-authorization workflow
Manage pre-certification and authorization needs for inpatient and outpatient diagnostic and therapeutic services. Provide concurrent or retrospective inpatient authorizations after admission. Review denied admissions, days, and services and complete all necessary steps for appeal requests. Review each medical record, focusing on payer requirements, to get the proper authorization for all services scheduled and rendered.
Prevent complex authorizations from slipping through the cracks
• Clinical findings/documentation does not substantiate need for services. • Insufficient support for level-of-care decisions.
demonstrating medical necessity
Hurdle #4:
Documentation doesn’t always support care provided
• Clinical findings/documentation does not substantiate need for services • Insufficient support for level-of-care decision
Improve documentation, communication, and coordination with payer requirements
Get Real-time Insight to Facilitate the Right Care in the Right Place
Provides evidence-based guidance at the point of decision-making. Automates review to reduce errors linked to manual processes. Lessens the administrative burden.
Automate medical necessity review
Automate medical necessity review by extracting data directly from the EHR to complete the medical necessity review, helping ensure all relevant data points are included:
Reduce denials and compliance risk by ensuring billed codes are accurate and reflect the highest level of specificity. Identify gaps in diagnosis and procedure coding. Improve diagnosis capture and accurately record the level of service rendered. Flag missing or incomplete charts for faster resolution.
Tighten clinical documentation through services that:
Enables defensible, medical necessity decision making for more than 95% of admission reasons. Covers medical and behavioral health across all care levels, as well as ambulatory care planning.
Facilitate the appropriate care setting by instantly assessing the safest and most efficient care level based on severity of illness, comorbidities, complications, and the intensity of services being delivered:
Focuses on length of stay and highly complex cases that need specific clinical expertise. Applies additional scrutiny when decision-support tools conflict with a physician’s clinical judgment, providing additional documentation for medical necessity. Implements concurrent authorization services for admissions. Augments existing staff or trains your staff to build a strong internal prospective review program.
Utilization Management Services align care needs with reimbursement requirements. Our team:
Staff can misinterpret payer requirements. Payers may not correctly match mailed or faxed attachments to claims submitted electronically. Errors may lead to multiple mailings, causing delays. With increasing postage rates and industry-wide labor challenges, organizations can no longer afford the time and expense to manually print and mail attachments.
sending attachments efficiently
Hurdle #5:
Manual processes can increase error and denial risk
• • • •
Automating workflow helps improve efficiency, reduce risk, and reduce costs
Reduce Reliance on Manual Processes for Sending Attachments
Medicare Veterans Affairs (VA) Workers’ Compensation Property and Casualty A growing selection of commercial payers Other non-Medicare payers, including Medi-Cal
Automate the attachment process
Send attachments electronically—through easy bulk uploading and attaching documentation for many claims—streamlining communication, eliminating a 30-minute delay per attachment in sending, and saving $4.50 per attachment.
Track attachments until the claim reaches final resolution. Reduce the risk associated with overlooked payer-documentation requests.
Submit solicited and unsolicited supporting documentation electronically to:
3. 2019 CAQH Index®. Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed, 2020. caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf
• Finding experienced coding staff is challenging. • Tight labor market impacts hiring and retention. • Continuous education needed to stay current on regulatory changes.
coding claims accurately
Hurdle #6:
Errors can lead to denials, delays, and compliance issues
• Finding experienced coding staff is challenging • Tight labor market impacts hiring and retention • Continuous education needed to stay current on changes
Reduce denials and compliance risks while optimizing accurate reimbursement
Access the Necessary Expertise to Code Accurately and Consistently
1,100+ certified coders exceed industry standards of excellence. Can easily work in multiple software billing systems. Help address specific coding areas, including inpatient, outpatient, emergency department, ambulatory care, surgery centers, and provider-based billing locations. Help you improve coding accuracy with ongoing, periodic, or one-time coding assistance.
Partner with an outsourced coding expert
Partner with an outsourced coding expert with deep ICD-10 expertise and knowledge in 25+ specialties.
Ensure appropriate billing for documented procedures Optimize front-end and back-end billing to streamline operations and improve overall billing integrity Uncover trends and improvement opportunities so you can achieve financial and data-quality goals Ensure your team establishes best-practice coding and documentation compliance standards
Audit coding regularly to improve accuracy to avoid recurring denials or compliance issues Our team stays current on regulatory changes to help you:
• Missing/Invalid EOB. • Invalid provider information. • Missing/invalid drug information.
avoiding 'missing or invalid claims data' denials
Hurdle #7:
Claim inconsistencies are the second highest cause of denials
4. The Change Healthcare 2022 Revenue Cycle Denials Index
Avoid rework and denials, which can slow and reduce cash flow
Make Sure Your Claims Are Correct and Complete Before You Submit
Automated alerts show staff when and where claims need attention. Real-time claim editing capabilities within your HIS workflow let staff efficiently complete rework. Secondary claims and EOBs are automatically generated from the primary remittance advice (especially important for Medicare claims).
Tightly manage claims accuracy
Help increase your first pass claims-acceptance rate. Access one of the industry’s largest networks of payers to stay current with changing payer rules and regulations. Our solution also helps you spot new errors that may not have been a problem before, resolve them quickly, and avoid denials:
• Untimely filing denials comprise 4% of all denials. • Interruptions to your standard workflows can increase risk.
ensuring timely filing
Hurdle #8:
Although preventable, this error still occurs
5. The Change Healthcare 2022 Revenue Cycle Denials Index
• Timely filing denials comprise 5.4% of all denials • Interruptions to your standard workflows can increase risk
Improve efficiency, reduce risk, and better respond to the unexpected
Use Technology and Expert Services to Keep Claims on Track, Even During a Crisis
Shows when each claim has been received, released, or accepted. Helps you troubleshoot issues to keep claims moving. Allows you to use payer status and claim-assignment rules to assign claims, create work groups, and monitor claim volume. Helps ensure team members work the claims that leverage their expertise, enabling greater efficiency and preventing bottlenecks that can slow claims, causing you to miss important deadlines.
Improve transparency to spot and resolve issues before they cause major delays.
Improve transparency to spot and resolve issues before they cause major delays. Track claims throughout their life cycle via a color-coded dashboard:
Address timely filing denials, with additional resources to focus on added inventory or specific payers who have tighter timely filing requirements. Additionally, our teams can prepare proof of timely filing documentation to help overturn denials when they do occur.
View each patient’s financial clearance profile in one dashboard:
See eligibility details, pre-authorization, medical necessity, bill estimation, point-of-service collection capabilities, and more. Quickly spot where things are being held up or where key information may be missing. Proactively address issues that could lead to delays and denials.
Lack of streamlined workflows. Limited access to experienced resources, especially for clinical denials. Lack of actionable insights to prioritize denial management and prevent future denials.
efficiently responding to denials that occur
Hurdle #9:
Despite best efforts, denials can still happen
• • •
Maximize appeals success while identifying systemic issues
Automation Plus Expertise Yields Fast, Effective Denial Response and Future Prevention
Implement fast, effective denial response and future prevention. Maximize appeals success while identifying systemic issues. Streamline the appeals process for three levels of denied Medicare claims. Create and track appeals for groups of claims that have been denied by a single payer for the same reason. Ensure your appeals reflect the correct format using built-in, state-by-state filing and processing requirements. Access to standard forms and templates to facilitate a faster response. Track submitted appeals using a comprehensive, user-friendly dashboard.
Automate appeals when possible
Focuses on overturning denials and obtaining payment quickly to reduce A/R days and decrease bad debt. Leverages AI and robotic process automation to prioritize denial management efforts and automate workflows, including benefit verification and first-level appeal submission. Employs advanced analytics to identify root causes and provide actionable data regarding each payer’s denials. Works with you to create best practice processes for denial prevention and resolution.
Optimize appeals success by managing all details of technical, coding, and clinical denials. Using our extensive reimbursement knowledge and advanced technologies, we can help address the denial backlog and improve the denial recovery rate to accelerate cash. Our team:
Leverage skilled resources
Analytics can help you organize which denials to prioritize to improve reimbursement practices. They can help monitor trends and uncover denial root causes to improve team knowledge and process to prevent future denials.
Make data-driven decisions with analytics
using data to drive decisions
Hurdle #10:
With scarce resources, data and insights are critical to guide prioritization and decisions
Conclusion
Data and analytics help you identify metrics that matter and measure progress against goals. Lack of or siloed data prevents you from gaining valuable insights to drive improvement. Unable to explore data to identify the root cause or develop a new trend analysis.
Lack of streamlined workflows. Limited access to experienced resources for denials management, especially for clinical denials. Lack of actionable insights to prioritize denial management to optimize reimbursement and to prevent future denials.
Identifying trends, spotting issues early, and assessing your performance objectively will allow you to make decisions that consistently improve productivity and reimbursement.
Assess your performance against goals and in comparison to peers
Leverage Analytics and Benchmarking to Continuously Improve Performance
Use a dashboard to quickly identify problem areas via critical information compiled automatically and in near real time. Gain ongoing visibility into interdependencies of cross-functional processes and performance against financial goals. Leverage data-driven performance recommendations and set alerts when thresholds are not met. Access data across multiple functions, even with various revenue cycle systems in use.
Leverage data analytics to focus improvement efforts
Leverage tools to derive analytics, trending, and benchmark comparisons to continuously improve performance and assess your performance against goals and in comparison to peers.
Monitor downward trends to proactively address issues before they cause major financial impacts. Review process effectiveness and gain quick insight into the dollar impact of improvement opportunities. Benchmark performance against thousands of peer facilities. Review claim cycle performance in 20 key areas using consistently calculated, near real-time data to compare yourself to peers, the industry average, or industry best. Drill down to detailed analyses to identify root causes if performance starts to decline.
Improve visibility into performance with regularly updated comparative analysis data.
Be proactive about underpayment recovery by identifying and correcting underpayments, which includes looking at charges that were denied. The team also identifies claims that were underpaid due to contractual variances and pursues additional reimbursement. You can use our detailed denial and underpayment reports during payer contract negotiations.
To learn more about how Change Healthcare can help with all your revenue cycle challenges, visit our RCM Complete™ webpage
If You’re Ready to Start Tackling Your Denials Rate, We’re Ready to Help
Get in touch
We’ll listen to your challenges and help you determine the best approach to creating a downward denials trend for your organization.
For more information on how denials are impacting the industry, view the 2022 Revenue Cycle Denials Index
