Like many, I read lots of blogs and short articles so I can select the relevant topics du jour. The other day there was yet another article in Healthleaders about denial rates increasing by Jasmyne Ray; simple and informative. It suggests that RCM execs are having to revamp their payer strategies and offers some trailing indicators. [For example, a benchmark report found that the final denial rate on inpatient claims increased by 51% between 2021 and 2023, increasing final inpatient claim denials to $1.2B in lost revenue, supporting a recent State of Claims report from Experian Health that also highlights challenges.] Sure, we can blame payers, but we should also take some responsibility as providers and vendors. This is the US health system; we must choose to be part of the solution, the problem, or a complainer on the side. I made my decision long ago which resulted in the commercialization of the first perimeter defense solution to prevent denials. I’m not a sideline kind of guy. Let me explain. Our industry has used the term denial management for decades, referencing only reaction. I propose we shift the paradigm to preventing denials by curating data as it enters our systems. Perimeter defense is the practice of surveilling data for correctness, before it enters a system, and need-be, before it results in a claim or bill. Bad data is like a virus – once it’s in a system, it’s timely and costly to fix. Fixing it on the front end, or defending your perimeter, turns denial management into denial prevention. Let’s talk accountability. The payers think they’re being accountable by increasing requirements. So, they’re reducing waste and abuse, right? Providers feel victimized and as though there’s nothing they can do or they are reacting to what they believe to be a situation out of their control, while vendors acknowledge the scenario, right? Well, maybe. I get it -the system is flawed and everyone is trying to do their part independently. But I don’t accept that answer. Let's use new, modernized tools to fix some of the new, modern issues, not old stuff to fix new issues. Let’s make capturing accurate demographics, insurance inclusive of COB and even primacy simpler so front-end staff don’t have to be expert at data capture, while simultaneously helping already distressed patients. Since front-end staff are capturing most of the data on a UB, let's give them the best tools for the job. Let's empower them with a better source of truth, reduce their need to perform data hygiene, even reduce the need for decision making. We can, today, and with a single click. Furthermore, it doesn’t cost much if anything? That’s right, shift some denial management spend forward to denial prevention, and bonus; free up staff! Yeah, I agree with Ms. Ray - revenue cycle executives do have to revamp their payer strategies. But it starts with identifying the problem and determining if you’re reacting to it or preventing it. Happy Fathers Day!
Working to reduce the likelihood of denials by addressing vulnerabilities in data entry. Now that’s left side of the boom thinking. Proactive v. Reactive
Certified Revenue Cycle Representative, Certified Process Consultant
3wIt's definitely time for a paradigm shift! I've always felt that denial management assumes claim denials are usual and customary, which just shouldn't be. I love the thought of eradicating the term Denial Management and replacing it with a proactive, preventative maintenance mindset! We have the tools. Change the terms, and perhaps the mindset will eventually follow!