Strategies to Prevent Coding Denials and Increase Revenues

Medical coding is a complex and critical component of any medical practice. Because of the complexities, coders must be well versed in the details relating to procedures, specialties, payer guidelines and the healthcare system as a whole.

There is no doubt that coding professionals play an integral role in the success of a healthcare organization. However, even experts make mistakes. These mistakes can lead to denials and wreak havoc on the revenue cycle.

Preventing Coding Denials

Prevention starts by understanding the reasons for high denial rates, and identifying trends by diving into the data. Implementing an organized denial management process to track, assess and assign accountability is recommended since losing track of denials can have a serious impact on revenue. These tips, along with the steps below, are recommended to improve denial rates.

1. Act quickly. While nearly 20% of all claims are denied, almost 60% of these denials are never resubmitted¹. Practices should have a process in place to get denials corrected, preferably within a week. This is achievable by leveraging innovations such as Robotic Process Automation (RPA), which can be used in data transcription (e.g., moving data point from A to B) and/or appeal submission by replicating and substituting for human “clicks.”
2. Understand the when and what. To harness the power of technology effectively, providers must grasp the when and what — when in the coding process should we use technology and what should we use?For example, RPA and generative AI can be used in the coding process to reduce inaccuracy and to compile the correct and required administrative information. ML and RPA can also be used to review data post coding and prior to submission to ensure that the claim is properly constructed and will get paid upon first submission.
3. Learn from previous rejections. Tracking and analyzing rejection and denial trends helps differentiate them, making it easier to learn where problems occurred so they can be fixed quickly.
4. Quality over quantity. Previously, there was a push for the accounts receivable and denials teams to review a certain quantity of claims per day. Is the team wasting time on denials with minimal return? Devoting time to a smaller amount of denials — those with the most potential payoff — will create a larger impact on revenues.
5. Collaborate with payers. Understanding the appeal process from the payer side is key to staying ahead of the process. This will help keep track of deadlines, successful appeal strategies and payer appeal decisions.

The Role of the Clearinghouse

A solid relationship with the clearinghouse can provide additional assistance to providers. A clearinghouse has the capability to support and understand payer rules can help with developing claims edits. This will stop claims from being submitted prematurely, giving providers the opportunity to fix them when a known error is about to be submitted.

Learn more about TriZetto Provider Solutions, their clearinghouse, and end-to-end solutions that can improve your revenue cycle.

References
Mills, T. (2019, September). Why getting claims right the first time is cheaper than reworking them. Physicians Practice.