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Claims, Denials, and How the Best Organizations are using Analytics

Published June 22, 2022

Background

The healthcare industry has seen a 20% increase in claim denial rates in the past five years, and because of COVID-19, the trend is only becoming worse (McKeon). Healthcare organizations must work to identify root causes, simplify the appeals process, and develop prevention tactics to help mitigate the social, technological, regulatory, and financial implications at stake. So, what are the leading causes associated with claims denials?

One cause of the claim’s inaccuracies is a result of disparate systems and processes across PAS or EHR system upgrades which may cause backlog in accounts receivable (A/R). Additionally, complex claims processes have put more financial responsibility on patients due to the advent of insurance marketplaces and high deductible health plans. According to the American Medical Association (AMA), claims processing inefficiencies are estimated to cost between $21B and $210B per year (Reiner).

There are multiple players in the space across payers and providers. Every organization is experiencing a similar challenge.

Many companies lack the capable systems to detect issues in denials data. Organizations must understand the data earlier in the process to avoid the financial implications.

The Best Way Forward

Healthcare leaders like you are focused on increasing speed and accuracy of claims data while reducing costs. How should you go about doing that?

Leading healthcare organizations are utilizing data and analytics, in the cloud, to increase revenue and reduce costs associated with claims denials. Benefits of the cloud include scalability, reduced IT costs, security, and collaboration efficiency. An article from the Healthcare Financial Management Association states that “31% of hospitals manage denials manually using spreadsheets” (Reiner). This is an antiquated approach and will fail to identify the culprits early in the revenue cycle. Understanding and applying analytics, in the cloud, on relevant metrics like initial denial rate, rate of appeals, and win/loss ratio will not only increase revenue in the short and long term but will also ensure first time quality of the claim.

At Infinitive, we understand moving claims data to the cloud is a daunting task especially with PII, PHI and other data security implications, but the most progressive healthcare organizations are embarking on this journey to realize business outcomes.

Where to Get Started:

Leading healthcare leaders like you are leveraging Infinitive’s expertise in data & analytics to:

  1. Understand the use cases/main business questions to answer
  2. Clarify data sources that are relevant to use cases
  3. Gain executive-level dashboards to inform strategy going forward

Contact us for more information on how our claims analytics offering can help you reduce costs while ensuring the speed and accuracy of claims processing.

Sources:

McKeon, J. (2021, June 7). Over third of hospital execs report claim denial rates nearing 10%. RevCycleIntelligence. Retrieved May 18, 2022, from https://revcycleintelligence.com/news/over-third-of-hospital-execs-report-claim-denial-rates-nearing-10

Reiner, G. (n.d.). Success in proactive denials management and prevention. hfma. Retrieved May 18, 2022, from https://www.hfma.org/topics/hfm/2018/september/61778.html