What's Keeping You Up at Night? (Winter 2018 - Part 3)

Uncomfortable facts about …

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

• 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 according to a 2017 Advisory Board survey.
• Since 2015 successful appeal averages have fallen nearly 20% for Commercial and Medicaid payers.

• 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.

• Lack of 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.

• No 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.

• Coding Errors
✓ Consistently maintain updates in coding tool and systems.
✓ Ensure selected codes accurately describe services performed.

• Insufficient Documentation
✓ Diagnostic testing documentation and treatment notes must support coding.

• Lack of 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 both will decrease these denials.

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

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