Shifting the Focus from Denial Management to Denial Prevention

Feb 20, 2024

As the volume of denials continues to increase, hospitals and health systems need a more proactive approach to denial management and prevention. Providers are encouraged to move from a denial management framework to a denial prevention framework to capture appropriate reimbursement. This will decrease time to revenue by shifting from management and appeals into data, root cause analysis, and prevention. It’s important to remember the ingrained cost of a denial management system; even the most efficient denial management systems represent some form of financial loss. This is what differentiates denial management from denial prevention. In a typical denial management framework, your organization works to interpret denial data, combat denials, and craft quality appeals because the longer a claim stays in the denials process, the more expensive it becomes. On the other hand, clean claims are 1:1, dollar for dollar. A denial prevention strategy encourages clean claims from the beginning.

Let’s discuss some of the most common reasons organizations struggle with implementing a denial prevention process.

Disorganization & Poor Communication

Hospitals and health systems often employ various workflows and technology sources in tandem in the name of productivity. Without organization and thorough communication, this often leads to increased confusion and a disjointed workflow. A successful denial prevention framework requires consistent communication starting on the front end through the back end. It’s especially important cross-functionally for teams using a multidisciplinary approach to denial prevention. The information shared between the financial and clinical staff is the key to preventing claims up front by ensuring the accuracy of patient demographics and sufficient documentation. Poor communication often causes silos between data sources and internal systems; denials can get lost in the mix, leading to an abundance of denials and, therefore, an increased workload for your team.

Education and Training

Denial prevention strategies are front-end heavy and require proper education and training to implement correctly. Documentation, preauthorization, and registration can all be underlying causes for denials, so front-end staff needs to be trained to actively work towards prevention. Even minor mistakes—such as patient demographic errors—can lead to a huge loss of revenue down the line. A cohesive cycle relies on consistency down the line so that issues can be spotted and fixed. Properly educated staff will be more aware of their importance to the workflow and how to set claims up for success.

Lack of Internal Resources

The staffing crisis stemming from the pandemic is still prevalent in many health systems. Not having adequate staffing puts such a strain on hospitals that they might feel they don’t have time to implement a denial prevention system and keep their quality of patient care. Burnout of clinical staff is still a concern, and hospitals are suffering. RNs may not have the time or bandwidth to resubmit claims or analyze data in addition to their other duties, and staffing turnover is expensive. Couple that with inadequate denial management practices, and organizations are potentially losing out on hundreds of thousands of dollars.

Shifting to Denial Prevention

Organizations know that avoiding denials requires effort to address the root causes to address these problems adequately. The appeals process is a tool that healthcare providers and health systems can use to improve reimbursement, but ultimately, this is tediously protracted and expensive. The most effective solution to reduce time to revenue is to focus on a prevention framework rooted in data, analysis, and clinical expertise.

How TREND Can Help

TREND Health Partners’ CAVO® platform intakes and extracts data from medical records while utilizing a proprietary search functionality that allows pertinent data to be extracted at the click of a button without requiring a cumbersome visual review. CAVO® supports coders, nurses, and physicians in searching for documents supporting the diagnosis sequencing if the DRG assigned is consistent with the documentation and treatment.

To discover the additional revenue your organization could recognize by partnering with TREND, schedule a 20-minute solutions discussion below.