What most studies, vendors, and software companies fail to take into account is that the definition of a denial is subjective. This definition differs by physician, biller, and institution.
Nothing is certain
The word that most succinctly describes the healthcare industry is uncertainty. The regulatory climate moves quickly and can change directions rapidly, leaving little time for providers and their patients to adjust. Providers don’t know if their patients will be able or willing to pay the bills after a procedure is performed.
Questions to evaluate
If something is denied, but expected or per contract, is it truly a denial?
If a claim is paid to a certain extent, but not to the full allowable amount, should it be considered a denial?
Will certain procedure codes always be denied?
Do those codes need to be billed anyways?
How can all of this be tracked and measured?
- Most importantly, how can physicians and institutions collect the money they have earned?
Move Beyond Manual
AppealsPlus™ provides process and workflow improvement in identifying and appealing these underpaid and denied claims. It is a cloud-based solution that automatically analyzes ERAs and applies your business rules to place suspect payments and denials in the appropriate work queues. It adapts to comply with your payer contracts and timelines. It utilizes dashboards and key performance indicators to provide quantitative management and is used to drive improvement decisions. It uses Software as a Service (SaaS) technology for rapid deployment without capital expense, so return on investment is immediate.