Problem: Effectively manage rejections

Effective management of rejections and denials can provide significant cash flow and increased profitability to practices. Most organizations struggle with obtaining consistent results when managing their insurance denial/rejection process. Identifying that a problem exists with rejections is easy, but due to a lack of timely data and reporting, coupled with management time constraints, most organizations are unable to determine the root cause and implement affect process change-with consistent results.

Top Ten Rejections

• Coding rejection
• Duplicate claim
• Member not eligible with payor
• Non-covered service
• Authorization required
• Additional information required
• Patient responsibility due to member benefits
• Missing referring physician
• Performing provider not recognized
• Past filing deadline

Solution: Information influences the rejection process

A flexible reporting tool is essential to determining the cause of rejections, and monitoring operational changes made to ensure implemented solutions remain effective.

1. Required Rejection reporting allows management to:
   • Easily produce reports by plan, provider, specialty, department, location, rejection error.
   • Quickly track and trend rejections over time
   • Measure rejections in dollars and number of claims
   • Identify coding rejections by specialty
   • Identify deficiencies in internal data capture
   • Identify top rejections by procedure or diagnosis
   • Monitor and trend rejections (after operational changes)
   
2. Flexible tools provide the ability to:
   • Ask questions of the data in a real-time fashion
   • Quickly slice and dice or rank data based on number of claims or charges
   • Easily identify the top 20% of problem areas, causing 80% of rejections
   • See the detail of the procedures submitted and rejected by payer
   • Automatically highlight or flag problem areas based on thresholds
   • Quickly identify new rejection problems as they occur

 

Solution: Process Changes can be implemented based on Information
Once problem areas have been identified, operational changes can be implemented

1. Process change
   • Identify top rejection categories
   • Implement PCS workfiles to manage the rejection process
   • Identify and correct system deficiencies at the source, i.e. formatting fields, coding edits, provider numbers, etc.
   • Orient staff and physicians on proper coding criteria and charge capture
   • Implement eligibility verification process of patients
   • Use rejection reports to influence actions
   • Manage rejections proactively

    

   

Results: Reduce rejections to increase collections

1. For every 1% reduction in rejections allows an organization to realize an additional $250,000 to $500,000 in collections.
2. Top 5 rejections usual account for 70 - 80% of the total rejected dollars