Improving Denials Management at the Source

Hospitals, similar to other businesses, are sustained by getting paid properly for the work and patient care they deliver. The problem is the payors have many reasons to avoid paying the full amount billed or they simply deny the claim based on internal reasoning. Claims denials are on the increase as we head in to 2020. In fact, on average, health plans typically deny 5-10% of the total claims submitted. One way to greatly improve revenue cycle management is to use a predictive software (likely utilizing artificial intelligence) to pull the cases most likely to be denied.

Once the cases most likely to be denied are isolated, there are a number of ways the hospital can address the issue on a case by case basis. One such way that is proving to be an ideal solution is retaining physicians trained in coding to get into the details of each case (to get to the most micro level) and select the correct DRGs. In fact, most times, getting specialized input before billing submission will preempt a payor denial.

“Expenses are going up, reimbursements are going down — and leaving money on the table is not an option... we have to do a better job,” says Ken Hertz, FACMPE, a principal consultant with the Medical Group Management Association (MGMA). Utilizing a third-party revenue cycle partner to identify the claims most likely to be denied and then prepare those files for billing to avoid denials is becoming an integral part of revenue management.

FairCode combines the domain expertise of experienced physicians with modern data science and analytics technologies to increase hospital revenue. We bridge the gap between your attending physicians and hospital coders. The result? Patient acuity and Case Mix Index are more accurately captured with the correct DRG; hospital reimbursement adjusts accordingly. DRG Validation and physician conducted medical chart reviews happen in real time, significantly impacting hospital quality rankings, case mix index (CMI) and bottom-line results. From clinical validation and chart reviews to payor denial defense, our physicians and data scientists are part of your team! Add us to your existing CDI initiatives, and see the difference. Outcomes are measurable and significant. FairCode averages greater than 4:1 Gross Return on Investment in client hospitals and has been delivering hospital revenue solutions for over 18 years.