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Healthcare Claims, Denials and Rejections: Building process improvement from collaborative insights

Updated: Oct 29, 2018


Revenue Cycle Management Automation



Healthcare related businesses come with their own unique set of management challenges from patient experience, processes, and technology. With a growing set of compliance requirements and intricacies for the billing processes, when coupled with patient needs and expanding payer requirements, the task of staying current in the day to day becomes vital to cash flow. As these challenges tax clinical and administrative teams, executing upon denied and rejected insurance claims can start to backlog. Insurance Payers understand this and, in some cases, count on the delays and lack of resources to delay payment. So how can we improve upon this stage of the billing process to optimize cycle time to cash?


Denials from insurance companies are notification to the providers that the claim in its original form does not meet the requirements for reimbursement. This can range from the minor checked box to more substantial processing of the claims data such as missing test results, patient documentation, etc. We can go deeper still as to the time-sensitive nature of denials and each insurance company has differing guidelines for timely filing. To this point, every payer has a different window for submission, from 30 days for initial claims to 90 days for resubmission. With a tight window for correction, quick action is paramount to success.


Denied claims should be monitored and quantified, reason descriptions allocated, and a method of follow up applied. At the time of payment application, all denials should be updated with denial reason codes, allowing for insights and analytics to identify your material process strengths and weaknesses. Collecting as much data as possible allows for actions and prevention of revenue leakage while supporting process improvement strategies, your insights, and analytics. Building the basic tracking and quantified causes by payer becomes a logical next step. Once the behaviors are visible, proactive planning and process strategies may be implemented. Or better still, negotiation points for your contractual arrangements.


Denied and rejected insurance claims can make the difference in an optimized revenue cycle management process and lend to faster cycle time to cash but also an improved patient experience. Spending the time to exam the full processes from new patient enrollment, pre-authorizations and through denial follow up and recovery will be completed in your internal process improvement strategies or part of your outsourced engagement model. In any model, optimization of cash performance is our role and with the access to internal or external resources, the business case for resourcing this area effectively creates greater value in maximizing claim value.


Rob Sherman, Chief Revenue Officer of VWi