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Lost Revenue Series - Part 2

Five Steps to Capture Lost Revenue for Hospital Outreach and Outpatient Services | Part 2: Enhance Denial Management Capabilities

This blog post is part two of a five part series. View Part One. View Part Three.


Part one of this series explored the adverse topline and bottom-line impacts of using an EHR system to manage outreach and outpatient services billing. We learned how the front-end automation functionality of a purpose-built revenue cycle management (RCM) system, used in concert with an EHR platform, mitigates these effects. This added capability decreases the frequency of downstream employee interventions and dramatically increases the number of successful claim outcomes.

The next step toward capturing lost revenue for hospital outpatient and outreach services involves augmenting claim denial management capabilities.

According to The Advisory Board, uncollectable hospital write-offs grew 90% from 2011 to 2017. The average successful appeals rate for hospitals declined from 56% in 2015 to 45% in 2017. Outpatient and outreach billings are particularly susceptible to this shift based on the relatively low dollar amount for these services and employee intervention costs to manage appeals. How can hospitals avoid these unwanted outcomes?

The solution, in part, is to employ a more robust, technology-driven denial management process designed for higher volume, lower-dollar transactions. Relevant functionality include:

  • Payor connectivity with real time claim status, for faster notifications and responses.
  • Automated appeal processes, including override reason codes and prioritized actions.
  • Integrated NPI and physician checks for compliance.
  • Denial code management to initiate responses (i.e., correspondence, bill next payor, or appeal).
  • Automated attachment of supporting documentation such as medical records and pathology reports.
  • Ability to access lab-specific appeals functionality (e.g., molecular testing).
  • Payor-specific front-end edits, supporting custom payor rules.
  • Automated bulk appeals.
  • Support for prepopulated payor-specific letters and forms.

In addition to claim level functionality, consolidated views enable monitoring of the overall appeals process, root cause analysis, and more effective decision-making. Common analyses include:

  • Which appeals are successful?
  • How many appeals have been sent?
  • What payors do we appeal most and for what procedures?
Payment And Appeals Dashboard

Productivity data further aids administration of the denials handling process, providing visibility into error processing activity, timelines, and success rates (measured in units and dollars), with drill-down capability. This information is used to delineate:

  • Team and individual performance for error processing
  • Timelines for resolution
  • Effectiveness of error fixes
Error Processing Staff Performance

Interested in reading the rest of this series? Subscribe to our blog. View Part 3, “Capture and Exploit the Right Data” to learn more about how XIFIN business intelligence can streamline and optimize denials, productivity, and payor management view the videos below featuring our customer Cordant Health Solutions.


Published by XIFIN
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