The Ultimate Playbook for Mastering Claims Denials and Winning Appeals
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CLEAN CLAIMS RATE A clean claim is one that contains no errors, includes all necessary information, and is paid by the insurer on the first submission without being returned to the provider for correction. To calculate the clean claims rate, divide the number of claims that meet the above criteria by the total claims submitted to payors. Include the clean claims rate and root cause trends of unclean claims on the KPI scorecard. Submitting clean claims upfront means more consistent cash flow and avoids additional costs associated with reworking claims.
Keys to Success:
• Regularly monitor your clean claims rate to quickly identify and resolve inefficiencies or problematic trends. • A positive variance in the clean claims rate may indicate successful process improvements or stakeholders learning from past errors and not repeating them.
• Conduct regular quality checks to ensure that there are no errors or missing data in the claims.
• Routinely validate that your claim processing technology is functioning optimally, fully updated, and accurately reports all key data elements.
• Educate stakeholders in understanding errors and their role in clean claims.
CLAIM DENIAL RATE The claims denial rate is the percentage of claims refused payment by insurers. As the number of denied claims increases, an organization’s financial situation becomes more precarious. Improving the claim denial rate is critical to maintaining a healthy revenue cycle. Create a claim denials dashboard that is part of a KPI scorecard.
Keys to Success:
• Stay close to your organization’s historical and current denials data. It provides benchmarks, trends, and other valuable information to make informed decisions about improving revenue performance. • Monitor the number of claim denials the organization receives and the impact on revenue. By regularly monitoring this data, you can easily identify emerging patterns or trends and take corrective action early on, either locally or enterprise-wide, before they escalate into more significant issues.
• An increase in denials could be a warning sign of shifting payor trends or emerging internal problems.
• A decrease may indicate successful outcomes from process improvements.
• The denials dashboard should categorize denials by type, such as medical necessity, coding denials, and clinical validation. Additionally, it should show the responsible department, financial implications, trends, and appeals outcomes. • Fix process-related roadblocks immediately, such as denials not reaching the appropriate department by the due date. It will be found money!
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