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Denial Management through Intelligent Automation

Any successful company, including hospitals and other healthcare facilities, is built on its administrative operations. However, manual Provider back-office procedures overburden staff with time-consuming, boring, and never-ending tasks. Operational procedures including appointment scheduling, insurance claim processing, and prior authorization submission not only put a physical strain on hospital administrative employees across the US, but they also cost the healthcare denial management software system money and divert providers’ attention away from patient care.

What is the reason for these high amounts of spending? Well! Health Plans typically reject 9% of hospital claims. Which forces the administrative staff to spend their time managing denials and filing appeals. The hospitals are left with a vicious cycle of claim rejections, a workforce well-versed in managing denials, and frustrated patients as a result of delayed or denied claims if we assess the average cost paid per claim and the time the administrative staff spends on denial appeal.

How can providers use intelligent automation to improve denial management?

Did you know that 90% of denied insurance claims may be prevent? 4 Despite this, they keep happening often and costing the average hospital $4.9 million each.

Manual processes

Nevertheless, manual denial management procedures are still use by 31% of healthcare providers in the US. 5 This delays the entire process and increases the amount of time and money spent on each claim while causing errors at various levels and across workflows.

Providers must use Intelligent Automation, a system that combines Robotic Process Automation (RPA) and Artificial Intelligence (AI) to streamline and expedite the claim resolution process, in order to save administrative costs and enhance patient experience. By mimicking manual human activity and enhancing it further by introducing machine learning and decision-making logic into the process, intelligent automation can assist in completing basic activities across applications.

Providers can gain from using Intelligent Automation at every stage of claims processing by:

Data accuracy

14.6% of claims are reject because of incomplete or inaccurate data. 4 By categorizing and evaluating the documents in real-time, intelligent automation aids with their digitization. By utilizing ML capabilities like Optical Character Recognition (OCR), it helps gather reliable data while reducing the likelihood of errors and missing or invalid data. It also offers deeper insights, minimizes data entry errors, and aids in categorizing the documents into pre-programmed categories.

Improved decision-making

Intelligent Automation assists company leaders in quickly gathering information about business operations by automating repetitive procedures and enabling deeper data analytics. This improves decision-making for handling denials and boosts income for providers.

Enhanced customer experience

By combining knowledge and insights to help you better understand patient requirements and deliver the experiences they desire, intelligent automation promotes a positive patient experience.

Increased compliance

Hospitals and other healthcare facilities handle enormous volumes of private and sensitive information. There is a higher possibility of non-compliance and data breach with manual processes. Data regulations are complied with, data inaccuracies are minimize, and the risk of a breach is reduce thanks to intelligent automation. With the aid of encryption and additional layers of security. This also prevents sensitive information from getting into the hands of unauthorized users, hence lowering the risk of non-compliance.

Providers can gain extra advantages by utilizing intelligent automation

Claims denial management is a challenging process that is prone to mistakes and inefficiencies, which over utilizes time and resources. However, the result is still the same—delayed, unsettled claims, disgruntled patients, and lost money for hospitals. By utilizing Intelligent Automation and automating the denials management process, providers may shift to patient-centric systems that will reduce risks, stop revenue leaks, and guarantee financial stability.

In order to assist you swiftly decide what to automate in order to obtain the best results. First source combines its considerable automation knowledge with a thorough grasp of the financial management processes used by healthcare providers. Automation is a viable option for many revenue cycle management procedures. Intelligent Automation creates end-to-end automation with bots in conjunction with Natural Language Processing (NLP) and automated data extraction tools like OCR for previously unheard-of efficiency, compliance, and experience.

6 Reasons why Claims are Denied

The rise in claim denials in the healthcare management system is cause by a variety of variables. It is natural that denials happen given how complicated the medical coding and billing system is, regardless of who is at fault—the payer or the provider. To guarantee that patient information is record accurately and claims are submit on time, providers must collaborate closely with their in-house or external medical coding specialists.

The healthcare revenue cycle of a facility may be significantly impact by poor claim processing management. A team of expert medical coders at ECLAT Health Solutions can offer the hospital billing and coding solutions you require to keep your healthcare center operating smoothly. Our goal is to simplify a favorable patient care experience by offering precise medical coding and billing services. The six most frequent causes of claim denial concerns at medical facilities.

Incorrect insurance claim ID number

Every time a patient visits, the physician is require to confirm all of the patient’s current information, including any recent changes to insurance. An insurance company or payer might not accept outdated IDs or insurance cards supplied with an initial claim. Medical coding and billing errors can also come from manual data input, particularly if staff workers lack the necessary data entry skills.

There are late filings of claims

Every claim has a deadline within which it must be submit and evaluated for payment. A healthcare provider frequently has to pay for a claim that was not submit by the deadline on their own dime. The majority of the time, incomplete or lost super bills—also known as charge tickets or an itemized record of patient services—can prevent healthcare practitioners from timely filing claims. Claims that are amended but present after the filing date may still be reject.

Separate service reports are provided

Because they are either Carrie out by a single physician or a team, some procedures shouldn’t be categorize or billed as a group. Additionally, it’s crucial to keep in mind that doctors could work for a practice that isn’t cover by a patient’s insurance. So certain services shouldn’t be bundled together. By being familiar with the services offered to the patient and the healthcare facility’s bundling policy, a professional medical coding and billing provider can reduce claim denials and the need for coding revisions.

Services not covered

A service might not be regard as medically necessary in accordance with payer policy because of the diagnosis listed on the claim. The staff members in charge of the facility’s medical coding and billing management system may not have been inform of the patient’s real diagnosis. Even though a therapy was administer to the patient base on the healthcare provider’s documentation. Even with increased awareness of a provider’s services and associated diagnoses, preventing coding and billing problems due to incomplete documentation can be difficult.

Inconsistent data

A refusal of the services and processes rendered is frequently the result of erroneous data being record on a claim. Data inconsistencies may occur for a number of reasons, including incorrect data entry or an inaccuracy in the documentation of gender-specific conditions. It advise that anytime a mistake or inconsistency arises, practices employ alert mechanisms. The error will prevent the claim from being process and deny if an alert system put in place, saving providers more time and money.

Misuse of a Modifier

For instance, modifier 25 denotes an evaluation and management (E/M) service that was render concurrently with another service. While modifier 59 denotes processes that were perform on different days. If the service catered to a different organ or another provider. If it didn’t fit within the original service’s normal schedule, those factors are also consider in modifier 59. Denials are prone to happen when modifiers are apply incorrectly. Denials can be significantly decrease with the help of knowledgeable medical billing professionals by adding the required common modifiers to the right service or operation.

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