Process Improvement Can Prevent Denials

Health system remittance data for the first quarter of 2017 reveals process breakdowns in patient access, and claims and billing continue to escalate accounts receivable days.

Almost two-thirds of the top 10 reasons for denials were related to patient access issues. The top two reasons, failure to check patient insurance eligibility and failure to ensure the service was covered, resulted in 49 percent of the top 10 denials. Other patient access issues included failure to check for medical necessity, failure to request authorization, and care scheduled outside of the network.

Claims and billing departments were the sources of 37 percent of the top 10 reasons for denials. Missing claims data accounted for 16 percent of the top 10 denials. Other reasons included duplicate claims, claims errors, errors in coding appropriate level of care, and lack of timely filing.

Staff education, performance management, and improved use of technology offers the opportunity to prevent denials and unnecessary write-offs.