Then, respond to at least two other peers who have chosen topics different from yours. Include the following details in your response:
- Assume you are the revenue-cycle director for the team, and you are tasked with correcting the causes identified in your peer's post for the claim denials. Describe how insurance participation may or may not contribute to a denial and how you would communicate with the insurance company when filing an appeal.
- As the revenue-cycle director, how would you approach the staff involved in the revenue cycle and correct the internal process breakdown?
* speak in first person
Tracy Discussion:
Having an efficient medical claims billing system is critical to easing the challenges associated with claim denials and ensuring the sustainability of providing healthcare services. World Health Organization describes medical billing errors and healthcare fraud as ‘the last great unreduced healthcare cost’. In 2014, WHO estimated that cost of fraud and incorrect payments in the world’s healthcare systems is about 7% of total global health expenditure, or US$487 billion. Health insurance companies reject 14% of healthcare providers’ claims, amounting to US$262 billion annually. In addition, the denial of claims puts a cost burden such as cost recovery on healthcare providers. Technology and human errors may contribute to a denial by the insurance company of the claim not being specific enough, missing information, or not filed on time.
From the front end of the process, the encounter with the patient could produce challenges from incomplete or inaccurate patient data collected during registration. During the registration process, patient demographic or insurance information could have been entered wrong and not caught prior to completing the registration process. The middle-end of the process would be where the clinical documentation from the healthcare provider is happening. If the provider is not documenting the proper diagnosis that the patient is properly being billed for, it could result in a delay. And as for part of the back end it could lead to a claim denial if it is coded improperly from the clinical visit. Having accurate and complete information throughout a patient’s visit is a claim processing best practice. The speed, accuracy and effectiveness of claims processing are important for controlling costs, managing risks and meeting underwriting expectations.
Adzakpah, G., Dwomoh, D. Impact of digital health technology on health insurance claims rejection rate in Ghana: a quasi-experimental study. BMC Digit Health 1, 5 (2023). https://doi.org/10.1186/s44247-023-00006-3
Hawayek J, AbouElKhir O. Problems with Medical Claims that Artificial Intelligence (AI) and Blockchain Can Fix. Blockchain Healthc Today. 2023 Jul 25;6. doi: 10.30953/bhty.v6.273. PMID: 37545860; PMCID: PMC10403814.
Gee J, Button M. The financial cost of healthcare fraud 2014. What data from around the world shows. 2014. https://researchportal.port.ac.uk/portal/en/publications/the-financial-cost-of-healthcare-fraud-2014(07b9046e-db06-43b0-83fa-b26272c0a161).html.
Wislyne Discussion:
Claim Denials and Revenue Cycle
Introduction
Errors in coding, incomplete documentation, or other technology problems are the most common reasons stemming from claim denials in the revenue cycle (Peterson, 2022). Knowing the causes behind such denials is key for healthcare organizations to develop efficient revenue cycle management and maintain financial sustainability.
Technology and Human Error in Claim Denials
Technology is consistently advanced and plays a great role in the revenue cycle, but it also may cause claim denials through bugging or software errors (Perkins, 2021). Human mistakes, including data input and coding, are another effective reason to reject claims. Erroneous transmission of the statements or faulty coding may result in automatic rejections by the insurance companies. Just like insufficient documentation or factual errors, patient information that is incomplete or inaccurate can lead to claims being rejected or denied (Peterson, 2022). To mitigate these issues, healthcare entities need to implement reliable systems and processes to achieve appropriate and comprehensive claims submissions without errors, thereby reducing the possibilities of denials and ensuring the best revenue capture.
Internal Process Breakdown
In the front-end workflow, a problem might arise during patient registration when the medical team collects incomplete or inaccurate demographic information, and this could result in a claim denial if there is mismatched patient data (Perkins, 2021). The middle part of the workflow also has another cause. Coding errors or inconsistencies between diagnosis and procedure codes may lead to claim denial. This is specifically true when the documentation does not support the billed services. Besides, incomplete documentation or not getting authorization before processing certain procedures also leads to denials in the middle workflow (Peterson, 2022). The back-end processing of the claims also has its own set of issues, which include submitting claims with mistakes, following up on denied claims and failing to do so on time, which translates to a prolonged revenue cycle process and a potential loss of revenue. Besides, as the claim reconciliation or denial management process becomes inefficient, the resulting negative effects on financial performance can be much worse. To tackle these process breakdowns within the organization, we need a proactive strategy that includes staff training, process improvement, and technology solutions to make the revenue cycle more accurate and efficient.
Conclusion
Technology and human error hold a great deal of responsibility regarding the reasons for claim denials. If the breakdown of the front-end, mid-stream, and back-end workflows is not resolved, the problem will worsen. The internal process breakdowns should be attended which is very important for workflow optimization and the financial impact of claim denials’ minimization in healthcare organizations.
Reference
Paterson, M. (2022). Clinical Practice and Financial Management. In Clinical Health Psychology in Military and Veteran Settings: Innovations for the Future (pp. 39-60). Cham: Springer International Publishing. https://link.springer.com/chapter/10.1007/978-3-031-12063-3_3
Perkins, A. T., Haslem, D., Goldsberry, J., Shortt, K., Sittig, L., Raghunath, S., … & Nadauld, L. (2021). Universal germline testing of unselected cancer patients detects pathogenic variants missed by standard guidelines without increasing healthcare costs. Cancers, 13(22), 5612. https://www.mdpi.com/2072-6694/13/22/5612