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Claim Denial Management Lacks Experts: How to Fill the Gap


Need help with your denial management? It’s time to bring in the experts.

A recent survey from AKASA and the Healthcare Financial Management Association wanted to find out which revenue cycle tasks required the most subject matter expertise. They surveyed more than 550 chief financial officers and revenue cycle leaders at healthcare organizations and hospitals. Of the 15 revenue cycle tasks, they asked respondents to choose up to five jobs that require the most expertise.

The survey revealed that almost 80% of leaders said claim denial management required the most expertise. This is no surprise: denial management has become increasingly concerning for healthcare organizations today as they struggle to maintain their workforce and contend with rising resignation rates.

Read on to learn more about the need for denial management experts and practical ways healthcare providers can fill the gap.

The Increasing Significance of Denial Management

While denial management has long been critical to ensuring cash flow and providing effective patient care, it is becoming even more vital since COVID. Denials have been steadily increasing over the past few years. In fact, a recent study found that insurers denied 17% of in-network claims. One insurer even rejected 80% of claims in 2020.

These increasing denials have serious cost implications for hospitals. With every denial, there’s a cost associated with reworking the claims, including staff time to research, correct, and resubmit the claim. Such costs add up significantly over time.

 Denials also slow down the reimbursement process, leading to decreased cash flow. It can affect the financial health of healthcare organizations, potentially leading to budget cuts or a reduction in services.

Denials can also negatively affect patient care in various ways. If a patient’s insurance claim is denied, they may face unexpected costs, which lead to dissatisfaction and a deterioration of the patient-provider relationship. Patients often ultimately bear the cost burden if their insurance claims are denied and they cannot afford out-of-pocket expenses. It leads to significant financial hardship for many patients and even dissuades them from seeking necessary care.

Plus, the time and effort spent handling claim denials divert resources from patient care. For instance, if medical staff are involved in correcting coding errors or providing additional documentation, they spend less time with patients. In some cases, if a patient’s treatment is subject to insurance approval and the claim is denied, there can be delays in receiving care. It potentially leads to worsening health outcomes.

The Need for More Experts

Workforce shortages compound the challenges of denial management. A recent survey of hospital CEOs named workforce concerns their top issue in 2022.

This critical shortage of claim denial management experts presents a significant problem for healthcare. The intricate and evolving nature of coding, regulations, and insurance policies requires specialized knowledge and skills to manage denials effectively.

Without the right experts to manage the denials process, the administrative burden of handling denials increases. This additional work leads to higher operational costs and removes resources from patient care.

Providers need to take a proactive stance to mitigate the impact of this expertise gap. Healthcare organizations can bridge the gap with the right steps, improving operational efficiency, patient satisfaction, and the bottom line.

Practical Solutions to Reduce the Burden of Denials Management

There are several ways that healthcare organizations can tackle the skills gap and shortage of denial management experts:

Training and Development. The first step is ensuring your current staff has the expertise and skills to effectively perform denial management. Investing in training will help prevent denials in the first place and ensure they proactively tackle them. Training you may want to consider includes financial management, medical coding, healthcare regulations, and efficient customer service.

Hire New Graduates. Some organizations may hesitate to hire recent graduates without all the necessary experience. However, they can fill crucial gaps with mentorship and training and become valuable assets.

Outsource Denial Management. If your organization does not have the time or resources to train your staff correctly, consider outsourcing to a third-party provider specializing in denial management. Their expertise can save healthcare organizations time and money as they navigate denial management.

Automation and AI. Automating some of the tasks related to denial management can free up staff members to focus on the complex cases that need their brain power. AI can help identify patterns and automate the follow-up process in the initial stages of claims denial.

In addition to helping with the denial management process, AI and natural language processing (NLP) can help prevent unnecessary denials in the first place with real-time quality checks and data analytics that can alert potential issues. Identifying these issues is becoming more crucial as providers struggle with quality control in the medical coding process. One study found that 90% of hospital bills have some kind of error. AI can be a valuable tool to prevent these unnecessary errors.

Robotic Process Automation (RPA). While much of the denial management process needs expert input, organizations can outsource many time-consuming parts to technology. RPA can handle repetitive tasks in denial management, freeing time for experts to work on higher-level tasks. RPA can handle data entry, processing claims, and following up on denials.

Cross-training. Training employees from other departments in denial management can help cover short-term shortages and allow flexibility in managing workloads. However, it’s critical to understand that this is a temporary solution. Overwhelming staff with expertise outside their role for too long can lead to even more issues down the road.

Develop Clear Career Paths. Many providers are experiencing labor shortages because of high resignation rates. Finding ways to keep your staff engaged with your organization and increasing retention is critical to overcoming the staffing shortage.

Having clear career paths in denial management attracts more skilled employees and keeps them engaged in the long run. Some ways to develop these career paths include providing regular opportunities for advancement and offering continued education and career development. When they see a future for themselves, expert staff are more likely to stay on longer.

It’s crucial to maintain a balance in denial management expertise. Automation and AI are critical to help ease the burden of employee shortages and improve worker productivity. Still, they can’t replace the human touch entirely, especially in a field as nuanced as healthcare. Investing in technology and people simultaneously is critical to managing denials effectively.

Bridging the Gap Towards a More Efficient Denial Management System

Healthcare providers face a daunting challenge as they navigate the complexities of denial management. The increasing number of denials, coupled with a shortage of skilled professionals in this area, is creating financial strain and impacting patient care.

However, these challenges can also serve as catalysts for change and innovation. Organizations can rethink their approach to denials management, proactively addressing the issue rather than merely reacting to it. By investing in training, leveraging technologies, and developing career paths, providers will start to close the expertise gap. GeBBS Healthcare Solutions can help you bridge that gap with innovative staffing and technology solutions. Visit gebbs.com to connect one of our experts today!

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