Real-time Data Analytics Crucial for Claims Denial Management

by | Last updated Jun 19, 2023 | Published on Sep 19, 2017 | Medical Billing

Data Analytics
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Efficient medical billing services are crucial for healthcare providers to optimize processes and leverage data analytics to maximize revenue inflow. Transparency in claims denial management with comprehensive data analytics are key qualities of a reliable medical billing service provider, according to a recent Revenue Cycle Intelligence report. The report illustrates the case of a New Jersey based urgent care practice that suffered financial losses, with accounts receivable reaching 65 days, due to inefficiencies throughout the claims denial management process. The reason: lack of comprehensive data collection and reporting by their billing company.

A recent Change Healthcare study that analyzed over 3.3 billion provider transactions from about 724 hospitals revealed that 9 percent of hospital charges in 2016 were initially claim denials. The study identified the top reasons for claim denials as:

  • Registration and eligibility issues (23.9%)
  • Missing or invalid claim data (14.6%)
  • Authorization and pre-certification issues (12.4%)
  • Medical documentation requested (10.8%)
  • Service not covered (10.1%)

The key to proper denials management is for medical billing companies to be transparent about these issues. The study showed that inadequate access to timely claim denial and reimbursement data prevented providers from recouping revenue for up to 63 percent of denied claims. In the case of the urgent care practice, their medical billing vendor failed to go after all denied or low-paid claims and did not provide timely billing reports, leaving them in the dark about their revenue cycle and overall financial performance.

Recovering claims reimbursement revenue is possible but involves significant costs. Change Healthcare reports that providers spent up to $118 per claim to make a claim denial appeal, which added up to $8.6 billion in administrative costs nationally.

Real-time access to claim denials management data is necessary to implement effective A/R solutions:

  • Leveraging data analytics will help healthcare providers develop claim denial key performance indicators (KPIs) and implement the appropriate technologies to manage the claims process. Keeping claim denial KPIs as low as possible will increase claim denials management efficiency.
  • Business intelligence tools help practices track claim denial reason. They need to track denials that are considered “hard” because the practice cannot prevent them. For instance, a practice can receive a hard denial for an annual covered service that was repeated within the same calendar year.
  • Data analytics also helps in developing a claim denials management KPI for “soft” denials – denials which are preventable. An example of a soft denial is claim with a wrong beneficiary policy number.
  • Advanced claim denials management KPIs allow analysis of denials by type and payer. Every insurance company has its own claim submission and reimbursement guideliens. Having payer-specific claim denial KPI will help physicians track which payers deny the most claims. They can then tackle these on a priority basis.

Data analytics allow practices to understand the different reasons for claim denials as well as the volume of rejections. This will allow them to focus on denials that are most likely to result in write-offs, which lead to lost revenue.

Another important strategy to prevent claim denials is upgrading or installing patient scheduling and registration systems. Partnering with a reliable medical billing company will help physicians allow practices to have patient information at their fingertips so that they can determine whether a claim can be appealed. Technologically advanced companies are equipped with sophisticated online software and a team of dedicated professionals to manage patient scheduling efficiently.

Outsourcing revenue cycle management is a feasible option for claims denial management. Reliable medical billing companies provide billing reports on a regular basis so that their clients get a real-time view into their practice’s financial performance and A/R. Using data analytics, they work with physicians practices to help them maximize claims reimbursement revenue in a timely manner.

  • Natalie Tornese
    Natalie Tornese
    CPC: Director of Revenue Cycle Management

    Natalie joined MOS’ Revenue Cycle Management Division in October 2011. She brings twenty five years of hands on management experience to the company.

  • Meghann Drella
    Meghann Drella
    CPC: Senior Solutions Manager: Practice and RCM

    Meghann joined MOS’ Revenue Cycle Management Division in February of 2013. She is CPC certified with the American Academy of Professional Coders (AAPC).

  • Amber Darst
    Amber Darst
    Solutions Manager: Practice and RCM

    Hired for her dental expertise, Amber brings a wealth of knowledge and understanding of the dental revenue cycle management (RCM) services to MOS.

  • Loralee Kapp
    Loralee Kapp
    Solutions Manager: Practice and RCM

    Loralee joined MOS’ Revenue Cycle Management Division in October 2021. She has over five years of experience in medical coding and Health Information Management practices.