One of the most time-consuming tasks in hospital revenue management is the resolution of payer denials. According to the American Hospital Association (AHA), denial rates range from 5% to 10% in most health systems, and a rate of lower than 5% is considered manageable. Health systems today struggle to keep enough full time employees on staff to work through and resolve all the various payer denials, which at the end of the day impacts their bottom line.
Our clients have reached out to us to assist with the ongoing challenge of managing technical and clinical denials. When our clients are unable to staff enough full time employees to handle the increasing number of clinical and technical denials, we provide skilled, experienced AR Analysts who can work, either onsite at our the client’s facility or remotely from our Atlanta office. With remote access to our client’s systems, we are able to provide staff at an hourly rate to resolve denials, and we cover all benefits and management of the staff we provide.
The denials challenge is not going away, and savvy revenue cycle directors are finding creative ways to attack and resolve them. On the technical side, the AHA identifies the top denials as:
- Claim missing information/absent or incorrect patient demographic data/technical errors
- Duplicate claim submission
- Service already adjudicated
- Services not covered by payer
- Time limit for claim submission has passed
Small balance claims with these types of technical denials, in particular, can be processed more cost effectively when outsourced.
According to the Centers for Medicare and Medicaid Services (CMS), the top medical necessity denials include:
- Not deemed medically necessary (CO50)
- Information submitted does not support level of service (CO57)
- Information submitted does not support this many services (CO151)
- Service/equipment/drug not covered under plan (PR204)
- Non-covered because screening or exam done in conjunction with routine exam (PR49)
Hollis Cobb staff work hand-in-hand with hospital nurse auditors and coders to get medical necessity denials resolved faster and more efficiently.
Helping our clients manage their denials is just one more way Hollis Cobb has expanded our services to meet our clients’ ever-changing needs in revenue cycle management.