3 Ways to Simplify Claims Edits and Reduce Denials

Stringent insurer policies, like prior authorization and medical necessity requirements, are making it more difficult for private practice physicians to focus on the clinical side of their work. The American Hospital Association calls such policies “extremely burdensome” and cites them as the driving factor behind the recent spike in practice acquisitions by hospitals and corporate entities.

Since January of 2019, more than 108,000 physicians have left private practice. In 2021 alone, the number of private practice physicians dropped by 26%.

American Hospital Association and other organizations are pushing for policy reform to ease the burden on independent practices, but meaningful change is likely a long way off. In the meantime, providers who want to remain autonomous must take a measured approach to operate within the bounds of insurers’ strict requirements.

Your practice can accomplish this by simplifying the process of completing claims edits and strengthening your denial management strategy.

Benefits of simplifying claims edits

• Higher clean claims rate. Claims editing is an essential step in submitting clean claims. Your clean claims rate — the portion of claims submitted with complete and correct information the first time — directly impacts the speed and accuracy of your reimbursements.
• Fewer denials. Claims edits can stop denials in their tracks. Denials have the potential to seriously curtail revenue, since up to 60% of denials are never resubmitted for payment. Reducing denials not only prevents rework on the part of your staff, but considerably improves financial performance.
• Simplified training. Denial management is one of the most difficult RCM functions for new staff to pick up on. Streamlining the process will lead to a better employee experience, which is a win for your practice during the current phase of unprecedented healthcare staffing challenges.

3 ways to improve your claims editing process

1. Automate claims correction

Large health systems employ entire divisions of people who are responsible for ensuring claim accuracy. In a practice with just a handful of physicians, such staffing is neither practical nor financially feasible.  With cloud-based technology, you don’t need a legion of staff to tackle claims edits.

Instead, you can leverage proactive claim scrubbing that automatically processes error-free claims while flagging those with missing or incorrect information for further attention. From there, save time with click-to-fix claim correction and eliminate guesswork with clear error messaging and edit guidance.

Automating your claims editing process in this way can help you achieve a clean claims rate of 99% or better.¹

2. Leverage custom business rules

Custom business rules are bespoke application functions that are created based on your knowledge of payer requirements and your practice’s workflows. They can make a huge difference in the number of claims edits staff need to perform while making the edits they do need to complete faster and more accurate.

For example, let’s say your EMR does not automatically populate the last four digits of a zip code, but these numbers are required by some of your payers. Even a simple edit like this is easy to miss when you factor in the volume of claims coming through each day.

A custom business rule can correct the discrepancy, ensuring that the claims created for those payers automatically add the last four digits. This eliminates a time-consuming and reimbursement-slowing denial by proactively addressing a data entry error.

An ever-expanding set of custom business rules can greatly alleviate the resource drain caused by complex payer requirements. A solution like Claims Management Pro that can process these custom edits quickly, is key to keep cash moving.

3. Tap into industry expertise

In a survey of more than 500 healthcare financial leaders, 79% of participants said the task that requires the most subject-matter expertise is denial management. It’s also the most time-consuming task in the revenue cycle.

Selecting an experienced RCM partner can take the burden off your shoulders, giving you access to specialized denial management guidance for Medicare, Medicaid, and commercial insurance claims. Address denials with confidence and achieve a higher first-pass yield in the process.

Improve claims accuracy and acceptance with Inovalon

Inovalon’s intelligent revenue cycle management solutions empower private practice physicians to spend less time micro-managing claims and more time diagnosing and treating patients. Proactively correct claims errors and perform edits with an all-in-one clearinghouse while consistently staying on top of your financial performance with comprehensive revenue cycle analytics.

Learn more about Claims Management Pro and RCM Intelligence. Request a demo now.

Sources:

1. Inovalon internal reporting, Claims Management Pro, July 2022

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