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Denial management innovations accelerating

Automation is the key to improving reimbursement

Professionals entrusted with claim denial management are like good ER doctors: they know that time is of the essence.

“When you get a denial, it’s important to know as early as possible because there are time limits for making a correction,” said Don Johnston, CIO at San Joaquin General Hospital in French Camp, Calif. “We use a web-based product from IVANS that gives us very prompt notification.”

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“Commercial payers are way behind Medicare when it comes to electronic claims submissions,” noted Michael Schramm, president of IVANS Healthcare Services in Stamford, Conn. “We recently conducted a survey that revealed that more than 99 percent of providers are submitting Medicare claims electronically, and about 89 percent do so for Medicaid claims. But 39 percent of providers still use paper to submit claims to commercial payers. We’re seeing steady progress, though, because there are obviously many incentives to automate. Studies show that about 80 percent of all electronic claims go through with no problems and no denials.”

The high success rate is due in part to the innovation and specialization of software solutions that help track and minimize denied claims.

Some of the biggest innovations are in analytics and workflow management.

“We have a new Revenue Analytics tool that will help hospital leadership perform more advanced analytics to make adjustments that will prevent future denials – and to have informed conversations with payers about claims denied in error,” said Karen Thomas, director of product management at Nashville-based Emdeon.
The company also pays close attention to denial workflow, helping ensure that a claim doesn’t get sidetracked in the wrong department. “Emdeon Denial Manager is a workflow tool that allows providers to work all remittances and to triage, track and report denials according to the provider’s own denial management protocols,” Thomas said.

There are a growing number of denial management products specifically tailored to medical specialties.

Zotec Partners in Carmel, Ind. offers tools tailored to radiology, pathology and anesthesiology groups.

“Our many years of experience working on behalf of these clients in an ever more challenging reimbursement environment brings immediate advantages to these practices,” said David Law, sales and marketing partner at Zotec. “We offer extensive denial tracking by diagnosis, physician, procedure or location.”

Law added that denial management is just one component of an organization’s overall billing and reimbursement program. “We think it’s equally important for our clients to monitor contract variance,” he said.

“That’s why we load into our Electronic Billing Center the terms and conditions of payer contracts – and the system then monitors whether the practice is being paid the contracted amount. This gives the practice sophisticated tools to call payers to account on every discrepancy, every time.”