The State of Claims and Denials in 2023


How do you resolve a repeated and shooting up problem like claims denials?

It’s been a fresher subject for revenue cycle management professionals for years that are only experiencing hotter with the growing pressures of staffing shortages, troubles with staff movement and instructing and developing policies and protocols at the government and payer levels.

On the macro-economic classification, denials play a part mightily to the expanding problem of unpaid care in America, presently calculated at $43 billion a year, and a latest survey of provider organizations established the rate of claims denials growing year-over-year at a 10%-15% clip as a consequence of space created along each step of the patient’s financial journey – from scheduling to access and registration to coding, billing and collections.

Related Article:

7 Most Common Reasons for Claim Denials in 2023

What’s operating denials? According to those same survey dialogists, the best 5 drivers are authorizations (48%), provider eligibility (42%), code inaccuracies (42%), incorrect modifiers (37%), and failure to meet submission deadlines (35%).

But desire rings everlasting among kind, empathetic, creative revenue cycle management professionals covering the country at health systems large and small.

Case in point: The Director of Revenue Cycle of a health systems company has overturn the narrative about the role of his department by reducing the company’s bad debt by 184% over the past decade, plus giving a net new $2 million in revenue deduction improvements to the system.

The way our leaders are reasoning about it now is that we can literally grow the reimbursement rate, and that has even striked some of the budgets we’ve been able to tight, and the ways we execute our tools and our exercise.

Key to that new account is Salwei’s framing of the issue as well as the solution. For Salwei, data equivalents patient satisfaction and cash, and he trust that achievement is based on how suitable your data is to create informed resolutions. That being the case, Salwei says, revenue cycle management is just a imitative of data management. Yet as a common rule of thumb, health systems pay people more to accurate their data upriver than they do to ensure standard data gets penetrate right the 1st time.

Stan’s Three Ps: Patient, Payer, Provider

When we speak denials in the shop, strategy-wise, the patient is the latest payer,” Salwei says. “Some people are only reasoning on insurance denials, but I’m attaching self-pay into that since what we have established using some of the tools we use is that we’re entwining in fund and bad debt chance due to some people having insurance so far in which they didn’t hear it to us, didn’t know about it or appreciate that they were entitled for federal, state and local coverage or marketplace enrolment.

As a sample, both states that the health system company presents have remembering Medicaid policies in place, defining people can collect coverage for health services got three months prior to filing for a Medicaid application if they encountered the eligibility demands at the time, which is condemnatory in view of many people who are not capable of applying Medicaid just after a major health event.

Here’s the obstacle we all have,” Salwei says, “we’re stressing to train patients the fundamentals of healthcare and healthcare insurance. Patients depend on us to do our jobs correct. The actuality is, most of people who work in the health system don’t even realize their own insurance and advantages, so it’s no ponder we have people approaching into the health system that frequently doesn’t realize their coverage, so we’re here for the patient to assist them in this journey.”

Health System company’s claims denial avoidance funnel leverages numerous tools and advancement to:

  • Get it right as early as possible (through real-time ability, coverage discovery and claims denial caution)
  • Automate the recognition, rectifying and presenting of denials corrections
  • Remain payers accountable for their contracts

They’ve also generated real-time dashboards, based on a set of adaptation codes, so that practice managers can literally go in and see their denial rates, percentages and give ups.

“Now that we have this data we can show it to our clinical areas and say, here’s the corrective action that we need to work in a row,” Salwei says.

Data and Technology are Key

Once regarded as a threat, the assurance of automation, artificial intelligence and machine learning now have hospital revenue cycle teams regarding such technologies as a way to label staffing shortages, grow job satisfaction and retain talent.

A 2022 survey of revenue cycle professionals over the country established that more than half (53%) say staff shortages pursue to decelerate claims and render of denials, and of those:

  • 1. 40% say they’re worried this collision cross-checking claims for errors
  • 2. 38% aren’t assured in a correct data exchange at registration
  • 3. 48% say patient approximates are correct 48% or less of the time, and
  • 4. 33% say the No Surprises Act will additionally screw up the claims process and adversely collide payor reimbursement

Given the results of the survey, it’s not unexpected that 75% of respondents consider reducing denials as their top priority. Additionally, 74% of participants plan to invest in claims technology and explore innovative solutions to streamline claims management, which can help reduce friction and increase efficiency. The primary causes of these issues are often cited as:

  • 1. Inadequate data and analytics (62%)
  • 2. Absence of automation (61%)
  • 3. Absence of staff training (46%)
  • 4. Absence of in-house expertise (44%)
  • 5. Dated technology (33%)

Given the circumstances, it’s understandable that health systems require both proactive and reactive solutions, along with partnerships that offer healthcare data and workflow expertise to provide the necessary support..

To be proactive, health systems can utilize advanced technology to detect claims that are likely to be denied and assess claims adjudication for each payer. This technology can also furnish systems and their revenue cycle professionals with reactive insights, enabling them to prioritize their efforts by focusing on claims that are more likely to be paid rather than wasting time on claims that have a lower likelihood of being paid..

While proactive solutions are important, it’s crucial to have easily adoptable solutions that integrate seamlessly into existing workflows and offer health system-specific modeling. Such solutions should be capable of adapting in real-time to changes in payer reimbursement policies and provide customized triggers that assist staff in identifying and resolving issues before claims are submitted.

It’s undeniable that claims denials cause significant disruptions for both healthcare providers and their patients. However, the good news is that technology solutions are being developed and implemented to mitigate these disruptions in non-disruptive ways.