The average healthcare organization’s claim denial rate continues to increase, and the current COVID-19 situation accelerated the growth. How much? According to the latest report, hospital claim denials are steadily rising and rising to 23%.

Lori Intravichit, CEO of Sunlit Cove Healthcare, said:

The good news is that most of these claim denials are potentially avoidable. The bad news is that there is no single silver bullet solution. Your organization has to look deeper beyond the coded cause and look for a root cause.

Here are the resources required to be successful in preventing denials and finding a root cause within your business office:

1. Collections

• A unit dedicated to working and appealing all denials
• Clerical staff experienced in collections and appeals
• A specially trained registered nurse for a clinical perspective
• Automated system to locate, track, and trend denials

2. Billing

• Staff dedicated to working edits
• Team to send out re-bills in a timely manner

3. Case Management

• Access to the case management denial work queues
• Engage a physician advisor to help with appeals: write letters and call payors

4. Coordination With Physician Office

• Recoding based on physician documentation
• Obtain additional office documentation for professional billing denials

5. Meetings

• Monthly or quarterly
• Coordination of efforts within the entire team

6. Financial Analysis

• Track denial by type and by trend
• Calculation of denial rate

Let’s face it; your organization will most likely never get claim denial rates to zero. Narrowing the focus to why payers denied claims and tracking common denial reasons are critical steps to moving towards a prevention-focused strategy.

Sunlit Cove Healthcare team can help your organization identify denial root causes and where in your revenue cycle most denials are occurring, which denials are avoidable, and provide strategies to help you prevent and manage denials in your organization. Contact us or give us a call at (727) 278-3009 to get started.

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Sunlit Cove Healthcare Consultants

We provide management and consulting services to help healthcare businesses run efficiently. Navigating the dynamic and complex revenue cycle management is a challenge for many health plans, health care vendors, and providers. Our consulting services are available to assist with your day-to-day operations and provide expertise in growth and change management. We manage all aspects of your enterprise from the development of the revenue cycle management process to the completion of your business cycle.

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