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Denials & Revenue Recovery Solutions

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Geoff New, MBA, RHIA, CHFP, CRCR, FHFMA, FAHIMA
November 30, 2023

The Challenge

73% of Revenue Cycle Management leaders rank staffing shortages as their primary concern.

Ongoing changes in reimbursement put immense pressure on healthcare providers. Two challenges identified by RCM (Revenue Cycle Management) leaders as significantly impacting financial stability and operational efficiency are staffing shortages and an escalating volume of claims denials. As the volumes and complexity of denials increase, RCM leaders grapple with the increased workload while striving to retain dollars to improve financial performance.

For many healthcare providers, existing solutions do not allow for sufficient denial workflow, management, or analytics. The scarcity of staff, equipped with the requisite skillset, further exacerbates day-to-day struggles in managing denials.

It is crucial for healthcare organizations to adopt a comprehensive denials management solution that blends the power of specialized staff and innovative technology. This synergy empowers organizations to navigate the complexities of denials and streamline revenue cycle process with fewer people, positively impacting the bottom line.

The Impact

Health plan policies are changing more frequently, forcing healthcare organizations to defend their documentation when denials occur. Ongoing changes in reimbursement put immense pressure on healthcare providers to manage the increasing denial volume while maintaining financial performance.

Denial Rates: In the first quarter of 2023, 15% of commercial claims were initially denied. This trend is not expected to change in 2024.

Productivity and Efficiency: 65% of denials are never resubmitted or fought. There is a significant effort and cost for a provider to resolve a denial in its favor. A lack of qualified staff and updated technology may also play a part.

Delayed Payments: Although most denials are eventually paid, the denial itself delays payment. A third of inpatient claims submitted by providers to commercial insurers were not paid for over three months. Even Request for Information denials may take 45 days to be paid.

The Solution

A comprehensive denials management solution offers a strategic combination of people and technology to address the challenges posed by staffing shortages and to streamline the denials management process.

Optimized Staff Allocation: With the rising demand for staff to manage denials, healthcare organizations often struggle to allocate their resources effectively. Specialized staff trained in denials management, optimizes staff allocation based on the organization’s specific needs. Dedicated teams lead to reduced overhead costs and improved workforce efficiency.

Maximized Technology Integration: Software that seamlessly integrates with existing RCM systems, empowers organizations to leverage the latest technological advancements without disrupting operations. Software should enhance staff productivity, enabling them to focus on critical tasks while automating repetitive processes, leading to increased accuracy and faster claim resolutions.

Proactive Denials Prevention: A comprehensive program should go beyond simply managing denials after they occur. RCM software should identify potential denial triggers by analyzing historical data and industry trends to empower staff with insights to prevent denials. This proactive approach saves valuable time and resources by reducing the volume of denials and preventing revenue leakage.

Datavant’s Denials Program: Protect – Connect – Deliver

Datavant’s all-encompassing approach to revenue cycle protects revenue by connecting an experienced team with technology to deliver a positive impact to the bottom line. Datavant’s comprehensive denials management solution goes beyond addressing the mounting challenges of RCM staffing; it embraces a consultative approach, delivering a transformative combination of skilled staff and state-of-the-art technology. By partnering with Datavant, healthcare organizations can navigate the complexities of denials management, elevate their revenue cycle performance, and achieve sustainable financial success amidst the dynamic healthcare landscape.

Datavant’s unique value proposition lies in the embedded presence within hundreds of healthcare providers and health systems, fostering profound insights into revenue cycle needs. Leveraging the extensive data on denials collected through release of information (ROI) services and robust relationships with health plans and healthcare provider organizations, Datavant offers unparalleled assistance in tackling denials.

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