Mastering Denials: Practical Solutions for Improving Appeals Performance

When discussing denials, it's important to recognize that the topic is…complex.

Denial rules can vary across healthcare facilities, influenced by factors such as contracts, payor mix, case mix, local coverage determinations, and staffing. Rather than getting bogged down in the details, we’ll take a broader perspective by highlighting best practices that can be applied across most settings.

Our focus is on actionable strategies that facilities can adopt right now, specifically improving the performance of appeals processing. With studies showing that 24 percent of denials cannot be recovered, it’s crucial to have a solid appeals process in place for the remaining 76 percent.

Here’s how to improve your approach:

Establish Clear Business Rules

Creating a set of clear business rules is a vital first step in building a process to address denials. Consider the following questions to ensure you're on the right path:

• Which claim adjustment reason codes should we always pursue or avoid?
• Are these rules specific to particular payor types or individual payors?
• Is there a minimum dollar threshold for denials that justifies pursuing an appeal?

By clarifying these aspects and establishing rules for categorizing appeals, you can make your team's efforts more effective.

Conduct Cost Analyses

Every week an account remains unresolved in receivables impacts your financial health. While some aging denials might need time to settle, once that time is up, aim to file an appeal within one week. Additionally, knowing when to stop pursuing a costly appeal can help avoid financial strain.

Conducting a cost analysis can provide insight into the expenses tied to specific appeals, helping you make data-driven decisions about which appeals are worth pursuing.

Monitor Performance and Train Staff

Even smaller teams should regularly evaluate performance. While oversight might feel burdensome, understanding your team’s strengths can be a major asset. For example, performance assessments could reveal which appeals coordinator is most effective with certain types of denials, allowing you to redistribute workloads and boost efficiency.

Benchmarking and Analysis

In addition to monitoring team performance, analyzing denial and appeals data is essential for refining your business rules over time. By evaluating success rates and associated administrative efforts, you can identify opportunities for rule adjustments to optimize your operations. Benchmarking against competitors also helps establish a baseline and gauge the effectiveness of your approach.

Ready to improve your revenue cycle?

MEDHOST is here to support your enterprise-wide revenue cycle management, including denials. Reach out to us at inquiries@medhost.com or call 1.800.383.6278 to learn more.