The Ultimate Playbook for Mastering Claims Denials and Winning Appeals
Four Pillars of Success
To achieve maximum revenue recovery from denials, it’s essential to have the right elements in place, including people, processes, and technology.
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PEOPLE Denials Prevention: A cross-functional team of experts from various departments is needed to prevent denials. This team should operate in lock step with those tasked with managing existing denials, consistently communicating denial trends and appeal results, sharing best practices and lessons learned, exchanging data, and developing educational materials. If your organization does not have a denials task force, it would be an exceptional achievement to take the lead on establishing one by assembling the right stakeholders from across the organization, as outlined in the “The Danger of Silos” section of this guide. Denials Management: Having the right talent with the necessary skills and knowledge is crucial for timely and effective denial management. A backlog can lead to revenue loss that could have been avoided, so it is important to prioritize aging denials by date and dollar value to ensure that appeals are submitted on time, and none are left behind. If an organization struggles with a backlog of denials or lacks staff to handle appeals, seeking external assistance is wise, as it will likely yield a significant return on investment. PROCESSES Well-defined, easy-to-follow processes are necessary for success, especially in complex areas such as claims denials. Every step in the process is significant. If any step fails, the revenue related to that denial is at high risk. Therefore, processes must be adaptable and flexible to keep up with the changing healthcare landscape. It is advised to periodically review current processes to ensure they are part of the solution and not the problem, meaning they are functioning optimally and not outdated. Here are a few tips: • UNDERSTAND YOUR CONTRIBUTION: All stakeholders must understand their roles, responsibilities, and impact on their organization’s financial health. • UNDERSTAND THE URGENCY: Everyone involved with denials should understand that every second counts due to the limited time available for appealing denied claims and recovering lost revenue. • UNDERSTAND THE JOURNEY: Map the current flow of denials through your organization to ensure each denial is categorized correctly and quickly routed to the appropriate department responsible for its resolution. • UNDERSTAND THE CHALLENGES: Identify inefficiencies in your process, such as bottlenecks or misrouting of denials to the wrong department and resolve them promptly. This is crucial to avoid missing the deadline for filing an appeal due to expired time limits. You should never lose the chance to appeal a denial by default because it reached your department after the filing date. • COLLECT THE DATA: Create guidelines for the standardized collection of denials and appeals data, including root causes, trends, volume changes, and appeals outcomes. This data is a valuable source
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