Providers and revenue cycle teams still have a lot of trouble with claims that are denied in today’s healthcare system. Repeated denials not only slow down payments, but they also make it harder for healthcare organizations to do their jobs and hurt their overall financial health. Root cause analysis helps you find and fix the problems that lead to denials.
Using good root cause analysis methods can help you get better results in your revenue cycle and cut down on the number of repeat denials, whether you handle your own repeat denials or hire a denial management service to do it for you.
What Repeat Denials Are and How They Affect You:
When the same claim or one that is very similar to it is denied more than once, it is called a repeat denial. Most of the time, this happens because the problems that caused it haven’t been fixed yet. These problems keep happening, and they could be caused by bugs in the code, missing information, problems with eligibility, or holes in the process. Healthcare organizations could lose money, have more days in accounts receivable (A/R), and have problems with payers and providers if they don’t have a reliable way to find and fix the root causes.
Providers can use denial management services to find claims that have been denied, fight them, and stop them. The best programs for dealing with denials don’t just try to get claims that have been denied approved again; they also find and fix the problems that stop claims from being approved in the first place.
When you get denied, it’s important to do a root cause analysis because:
Root cause analysis (RCA) is a methodical way to find out what is causing a problem. RCA helps businesses figure out why claims keep getting denied so they can come up with specific ways to fix the problem. By addressing the root causes, healthcare providers can reduce the number of denials in the future, speed up cash flow, and save money on administration.
Most of the time, denial management companies have access to experts, advanced analytics, and tried-and-true methods for doing RCA. This makes them great partners for healthcare companies that want to improve their revenue cycle.
Important methods for stopping repeat denials through root cause analysis are:
1. Getting and organizing data: The first thing you need to do for any RCA is to get a lot of information about denials. This includes not only the codes and reasons for denials given by payers, but also information about the company’s own processes, like how long it takes to submit claims, how to document them, and how to code them.
Action Point: Use denial management services to sort denials into groups based on their type, payer, department, and how often they happen. Companies that hire other companies to do work for them often have advanced tools that can automate this process and make reports that can be used.
2. The “Five Whys” Method: This method is simple and effective. You can figure out what’s wrong by asking “why” five or more times. For instance:
- What made the claim false? It didn’t have all the forms it needed.
- Why wasn’t there any paperwork? The provider didn’t send the surgery report.
- What kept the provider from sending it? They didn’t know they had to.
- What made them not know? It wasn’t clear what the need was.
- Why didn’t they say it? There isn’t a list that everyone uses.
You can either have your denial management team use the “5 Whys” method or hire denial management service outsourcing companies to help you run these workshops to find the root causes.
3. Fishbone (Ishikawa) Diagram: The fishbone diagram shows all the reasons why a denial could happen in a clear way. It puts them into groups based on people, processes, technology, rules, and things that aren’t part of the business. It’s easier to see problems and trends in the system when you look at the big picture.
What to Do: Set up regular RCA meetings with your in-house team or your outsourcing partner to talk about denial categories that come up a lot. You can use fishbone diagrams to help you.
4. Pareto Analysis (80/20 Rule): This method helps you find the “vital few” reasons why most claims are denied. Most of the time, only a few things lead to most of the claims that are denied.
Action Point: Make Pareto charts with denial management services or special software. After that, pay attention to the areas that will have the most impact.
5. Finding holes in the workflow: Make a map of the whole process of filing a claim from start to finish to find places where mistakes or missed steps happen a lot. When denial management service outsourcing companies that can do more than one thing do workflow mapping, it works best.
Action Point: Check your workflow after you change your payer policies or upgrade your system to make sure that everyone on your team is doing things the same way and the right way.
How Companies That Outsource Denial Management Services Can Help:
More and more, healthcare organizations are hiring outside companies to handle denial management. This helps them save money and get help from experts. Companies that hire people from other countries can help with good root cause analysis in the following ways:
- Advanced Analytics: Partners who do outsourcing use the newest analytics tools to find patterns of denial, root causes, and trends more quickly than if they did it by hand.
- Knowledge of the Field: Teams that have worked in the field before know the rules, coding standards, and payer regulations, which helps them with both analysis and process improvement.
- Process Optimization: Companies that do outsourcing can look at your processes and see how they stack up against the best ones to find ways to make them better.
- Continuous Improvement: Ongoing monitoring, feedback, and education make sure that the root causes are dealt with and that repeat denials happen less often over time.
How to Keep Denials to a Minimum:
- Train your staff regularly: Make sure that the front-office, billing, and coding staff know what the payers want and how to write it down.
- Use technology: Use automated tools to keep track of and report denials. This will help you figure out what went wrong.
- Work with Partners: Companies that help you deal with denial can help you come up with new ideas for how to grow your business.
- Keep an eye on the KPIs: The denial rate, the first-pass resolution rate, and the number of days in A/R are all important performance indicators that show how things are going.
- Get feedback often: Use the results of regular RCA to change the organization’s rules, procedures, and training programs.
Final Thoughts
You need more than just quick fixes to stop being turned down all the time. By using good root cause analysis methods and, if necessary, hiring outside help to handle denial management, healthcare organizations can make their revenue cycle work better over time. If your team handles denials on its own or with the help of outside partners, focusing on the root causes will help you get paid faster, have fewer denials, and make more money.
Want to make it easier to deal with your denials?
You might want to hire an experienced denial management service outsourcing company that can use advanced analytics, industry knowledge, and tried-and-true methods to find the root cause of problems if you want results that last.