Every problem has a solution. When we get to the root cause of it. Sounds easy doesn’t it? But is it as simple as it sounds? Well, it really depends.

The more complex the issue, the deeper we need to delve into the granular details of it. And so is it, in the case of Claim denial management. The more complex the denial framework and the operations, a more nuanced approach it requires—to streamline processes, optimize efficiencies and achieve sustainable results, all of which begins with understanding the one key component, that may be overlooked amidst the overwhelming responsibilities of a claims management team—the root-cause analysis phase.

This blog is a deeper dive into how Hospitals and Practices can leverage this untapped opportunity—to significantly reduce and prevent denials from the ground up!

The State of Claim Denials

To get a broader perspective, here’s what statistics of denials looks like in the current scenario! Claim denial rates are at an-all time high as per the 2020 denial management reports. 33% of hospitals and practices are nearing the danger zone with over 10% denial rates. Patient eligibility, inaccurate or incorrect claims, duplicate claims top the list of contributors to the massive spike in numbers. But, given that 90% of denials are preventable, here’s how you can take your first and most significant step to ensuring that you collect every dollar due.

Get to the Root Cause of Denials!

But, before we get to that, what is this root-cause analysis that we keep raving about?! Root-cause analysis is the first and amongst the most significant steps involved in denial prevention. A wealth of Claims management analysis reports suggest that it is a primary and foremost important step to a successful denial management process.

Various healthcare organizations take different approaches to evaluating the causes and efficiencies of their denial management process depending on the complexities of their denial workflows. While some Practices use claims management software with automation solutions to simplify the process, others may decide to take a manual approach.

A simple root-cause analysis can begin with evaluating the existing challenges in the denial management process based on the following checklist. Consider asking these critical questions to start with.

What are the key reasons for denials in your Practice?

• 01. Registration/Eligibility
• 02. Service not covered by Payer
• 03. Duplicate claim or service
• 04. Deductibles
• 05. Payer behavior
• 06. Case management
• 07. Coding errors

While the above checklist gives an overview of the major causes of claim denials, it’s critical that healthcare systems delve into the intricacies of the denial management process—in order to achieve long-lasting benefits.

Our Approach to Denial Management

Denial management strategies at SolvEdge, are designed with a proactive approach to denial prevention. The customized workflows help determine the root cause of denials. Once the denial patterns are identified, a detailed report is generated by evaluating the recurring causes of claim denials under various categorizations like the Payer, doctor, diagnosis and CPT codes. By leveraging these insights, we implement process improvements to reduce denials and optimize revenues.

The integrated Denial management framework includes proven strategies, industry best practices, and advanced analytical insights—that not just manage but prevent denials. Our data-intensive analysis has helped clients reduce denials by at least 35% and improve claim accuracy rates to a staggering 99%.

Take advantage of our hyper-personalized, result-driven root-cause analysis report to recoup every penny you deserve!

To learn more about how SolvEdge’s revenue cycle service offerings can help optimize your denial management ROI,
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