Insurance denials are an ever-present issue in U.S. healthcare. When an insurance company notifies you that it considers a certain treatment, service, or medication not part of your benefits, this is called a denial.
Receiving notification of a denial can be devastating for patients, both emotionally and financially, especially for those who are in a vulnerable situation with a serious health issue. Providers too must deal with the fall out of denials, as it takes time and effort to figure out why and how to adapt treatment where necessary, leading to delay and frustration.
According to Becker’s Hospital Review, 15-20% of all claims submitted result in denials and 65% of those denied claims are never worked with, which in return results in 3% loss of net revenue.
The challenge for healthcare organizations is to try find ways to reduce the amount of insurance denials that are coming back across all payors, and to develop systems and models to challenge denials when they do come back.
RelateCare provides a Denials Management Solution to healthcare organizations in order to assist with this process.
According to Modern Healthcare, there are three major factors that lead to denials:
- An overwhelming volume of automated reviews: Payer algorithms can quickly identify potential DRG downgrades and medical necessity issues, leading to a faster rate of denials.
- Increasingly complicated criteria: Revenue cycle leaders report that payers are also using more complex criteria for claim submission and medical necessity requirements, often layering payer-specific requirements over the CMS suggested criteria.
- The fine print in your contracts: Payer contracts include varying requirements ranging from medical necessity criteria to technical specifications. These small but meaningful differences can make it hard to submit compliant claims.
So the first step is to understand this process fully, or work with a partner, like RelateCare, that has the knowledge, experience and expertise necessary to gain a full and comprehensive understanding of the process. Only in this way can you begin to take the steps necessary to mitigate the amount of denials and successfully resubmit.
It is often the case that the denial can be successfully challenged by locating errors is in the original submission. RelateCare partners with organizations to work their preventable/avoidable denials, which accounts for 90% of denials, including registration inaccuracies, ineligiblity for insurance, invalid codes, medical necessities or credentialing.
Navigating the ever-increasing complexity of regulation criteria can be overwhelming for those with no medical background. Tracking each application and understanding where the error is can be exhausting and time-consuming for providers already under pressure from many angles.
Partnering with an organization with the resources and expertise to guide patients and providers safely and efficiently through the denials process can get rid of these headaches, while recapturing some of the lost revenue.