Leadership in Denials Management

Exceptional leadership and innovative solutions have improved patient care and risk management. Case management and interdepartmental IT integration have improved efficiency. Streamlining patient assessment and incorporating bedside admission technological are reducing patient stress levels. However, even with all of the positive adjustments in recent years, hospitals struggle to provide high-quality continuity of care without exhausting the operating budget.

Taming the Proverbial Beast

According to a 2008 study commissioned for the American Medical Association, the largest insurance providers denied an average of 4.75 percent of their claims. Many hospitals in the US expect approximately 3 percent of their patient claims to be returned unpaid. A substantial portion of these claims are denied due to improper coding and administrative failure to verify patient coverage limitations. For many hospitals this translates to millions of dollars in lost annual revenue. An evaluation of causation for denial exposes the potential for recovering a plurality of the lost funds.

• Incorrect service coding
• Failure to confirm length of stay limitations
• Failure to acquire pre-certification for inpatient care
• Failure to negotiate services and fees
• Lack of communication with private payers and third party payers
• Incomplete record
• Filling with inappropriate insurance company
• Insurance company error

Leadership: Intervention and Correction

Rene Letourneau of Health Finance News, discussed these issues in a recent article. Letourneau reveals that 54 percent of hospitals participating in a 2011 study have added more staff to address revenue integrity while 25 percent have created new departments.

Managers have a responsibility to their patients and staff to provide sound fiscal policies. Integrating technological solutions to reduce human error is one way to address denials. Increasing staff training and supervisory oversight is another. If managers fail to analyze data effectively, it is impossible to counteract faulty procedures and practices within their institutions. Effective leaders must evaluate their operations, delving into the details behind denials before they can execute solutions to improve revenue cycle performance.

This top down approach can certainly help achieve excellence in the healthcare arena.

Source: http://www.politifact.com/truth-o-meter/statements/2009/sep/18/health-care-america-now/tv-ad-overstates-health-insurance-denials/
Source: http://www.healthcarefinancenews.com/news/revenue-integrity-tops-list-concerns-hospital-executives