The transition to value-based care and more telehealth services requires healthcare organizations to make necessary changes to better support patients and streamline their internal processes. As telehealth has become more prevalent and policies surrounding it continue to evolve, organizations are strategizing their approaches to maintain quality care and a healthy revenue cycle. One of the most crucial approaches is to reduce denials rates.
Let’s explore the impact of reducing denials rates during the telehealth boom – a boom that is likely here to stay.
Recognizing the impact of denials rates
Not only have denials rates increased steadily over the last 5 years by 20% but we have also seen a far more rapid increase in the last year due to the pandemic. To avoid lost claims and increase recovery, it’s critical to implement a process that works.
Ultimately, denials mean lost revenue. They also means lost time as your organization works through the recovery process. The tedious challenges involved in recovery can quickly become an all-consuming problem without the right mix of experts to employ a prevention and recovery approach that speaks to your organization’s specific needs.
Common reasons that claims are denied include:
- missing or incorrect data
- lack of prior authorization or medical necessity
- patient eligibility
- duplicate or late submissions
- incomplete documentation
- procedure coding errors and invalid or outdated CPT or ICD-10 codes
But healthcare organizations also face skyrocketing denials rates due to challenges such as:
- lack of organization of data
- siloed internal communications
- lack of coordinated focus on prevention
- lack of appropriate experts who can identify various types of denials as well as the root causes for appeals, recovery, and prevention
Sure, denials will always will be a challenge – even with the most attentive organizations. But best practices can and should be implemented, and they must begin with banking on the proper experts who take a pragmatic approach.
Understanding denials and telehealth challenges
Organizations across the globe were able to successfully put telehealth visits and procedures into action, but no one can deny the weight of 2020 revenue losses. One study noted that “primary care practices would be expected to lose $67,774 in gross revenue per full-time-equivalent physician” and that “the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion.”
The authors recognize just how crucial virtual care services were to revenue generation though, noting the losses “could more than double if COVID-19 telemedicine payment policies are not sustained.”
As healthcare organizations hustled to provide a variety of virtual services during the pandemic, the government removed payment barriers and encouraged telehealth visits. This support allowed for more than flexibility and convenience; as noted above, it also allowed for an increase in revenue.
This is a perfect example of why healthcare organizations should consistently tend to best practices in denials management. Understanding changes in telehealth regulations and its evolving landscape helps you maximize reimbursements and reduce denials. But that relies on having the right mix of denials experts and the most appropriate tools and strategies in your pocket. Organizations that do can secure a healthy revenue cycle – even when the cards are stacked against them.
So what do those best practices include? Let’s take a look:
- verify insurance eligibility early
- use demographic data and verified insurance details to generate price estimations
- identify amount patients will owe to encourage understanding and increase likelihood of timely payment
- submit claims within 24 hours from the time of care to avoid gaps in cash flow
- capture correct denials data so the organization has a clear understanding of challenges
- analyze denials on a regular basis and categorize them to better understand causes, track trends, and improve reimbursements
The bottom line
Adhering to best practices is key. That includes partnering with experts who can plug into your organization’s process to customize a playbook tailored to its needs is what will amp up your denials prevention and recovery strategy.
Whether your organization would best benefit from a decentralized approach, a centralized approach, or a hybrid approach, having experts on board who understand the intersection of telehealth and denials and who can build a culture of accountability will drive lower denial rates.