Dealing with denied claims is a constant task in revenue cycle management. RevCycle Intelligence reported that there was a 20% increase in claim denial rates in the last 5 years1. Change Healthcare reports that the rates increased 23% between 2016 and 2020. Certainly, part of the challenge emanated from shifted focus during the pandemic but what else is driving the 6%-13% denial rate average across the nation2? What is driving the average rate of 9.7% in the Midwest2?
It certainly varies, eligibility and verification errors, prior authorization process failures, poor data entry, questions of medical necessity, the list can be exhaustive. That said, experts agree that the rate of denials can largely be tied to two things: front desk processes and employee training.
Front Desk Processes
Bad data in, is bad data out. It’s essential that staff are entering data accurately and verifying that accuracy on a consistent basis. This means your staff needs time to attend to their duties at the front desk which can include phone-only intake staff or any other role taking patient information for direct system entry. What this also includes, and what many don’t factor in, is having clean data management protocols. In order to define bad data entry, you have to define good data entry. If your staff doesn’t know, for example, that including the subscribers information as a question every time they discuss patient coverage, then they won’t focus on that as an area for completion.
Poor processes at the front desk lead to, at minimum:
- Slower revenue cycles
- Denials due to:
- Non-covered services
- Coordination of benefits issues
- Patient cannot be identified as our insured
- Duplicate patient records
When over 92%3 of denials come from data-entry errors made by the front desk staff, we must focus on our processes and protocols as a factor for improvement. Which is why we have to look at people, processes, and technology.
Most organizations have at hire training, competency exams, and some element of mentorship. Unfortunately, after that initial hire period the rate of training and education begins to trend downward. It makes sense in a way because the more experience staff gain, the less they need education to complete their daily tasks. There is a fine line however between competency and complacency.
Billing rules change annually, payer rules can change more frequently. If staff don’t have updated training on new payer plans, insurance card changes, new prefixes, then they are at a disadvantage for correctly capturing and entering patient information. Intake staff have a high speed job, with many patients, phone calls, and a host of interruptions. When time is at a minimum, quality begins to decrease. In those situations, you want their default habits to have a strong foundation which can only be achieved through training.
- Educate staff at least bi-annually on best practices
- Articulate and communicate how your practice defines “good” data entry
- Train to processes and audit process gaps
- Support your team with the proper technology and system training needed to drive efficiency
Every practice management system and clearinghouse offers different functionality. Staff that perform entry and billing should be at a super-user level of your practice management system to ensure that they understand how you want the system to be used. This is an area of training that should happen regularly to ensure proper capture of full patient demographics and to verify the accurate placement of data in appropriate fields because that is what drives clean claims and fuels our reports.
Track trends by grouping denial codes for additional insight and evaluating areas where you may need improved processes, additional training, or better use of technology. Managing and minimizing denials should be a consistent focus across many departments, but the front desk is a great place to start.
- McKeon, Jill. “Over Third of Hospital Execs Report Claim Denial Rates Nearing 10%” RevCycleIntelligence, article dated 6/7/2021 and accessed 3/4/2022.
- “The Change Healthcare 2020 Revenue Cycle Denials Index” org republication. Accessed 3/4/2022
- McCutcheon, Diane. “3 Reasons Why Billing Staff Relies on Accurate Information From the Front Desk”. Account Matters Blog, article dated 7/18/2018, accessed 3/4/2022.
Taya Moheister, EMBA, CMPE, CMOM