As of 2022, payer denial rates are hitting averages as high as 80%. This increase in denials severely affects hospitals by decreasing revenue and overloading staff.
Why the increase in denial rates, though?
Payers are rapidly gaining two things: knowledge and technology. Their algorithms are getting smarter, which drives up productivity without having to increase staff. Payers are advancing by leaps and bounds, however, on average, providers aren’t progressing as quickly on the same fronts. The COVID-19 pandemic took a toll on hospitals and health systems nationwide, and they are still scrambling to catch up. Denials are piling up, and providers continue to struggle with staff turnover.
How can providers beat the odds?
Moving from managing denials to being proactive with utilization management can be exceedingly beneficial to health systems. Hospitals looking to increase their revenue and patient satisfaction should start by transitioning to a utilization management process.
Even with advanced education and training, no organization has a 100% clean claim rate; however, understanding utilization review can help you increase that percentage. For example, payers are adopting new automated AI technology to work for them. Providers should consider adopting claims technology to lessen their workload. Analytics is key in creating a more efficient utilization management strategy.
Your UM team is going to work with hundreds of different payers and different entities throughout their careers. It’s critical that your UM team can collaborate successfully and communicate with the rest of your staff. There must be thorough communication from the patient-facing front end to the financial management back end. Revenue cycle integration is imperative for denial prevention because prevention relies on having the patient’s information correct, medical necessity documentation, and any other documents ready for submission.
Continued education is another way providers can decrease their burden. Education benefits staff regardless of experience or seniority, especially since payers constantly update their policies without warning. A claim denying because of outdated information is not an ideal use of resources, but it is preventable. Because utilization management is more than documentation; it’s about analyzing clinical factors, building a case, and understanding the patient’s clinical needs. Your team needs to be on top of their game during the patient’s stay.
If staffing is an issue for your organization, there are options. Find a partner with deep clinical expertise that remains current on payer guidelines so that your team can focus on other aspects of their job.
How Advent Can Help
Advent Health Partners breaks down our utilization review process into three categories: prior authorization management, concurrent reviews, and pre-bill reviews. The utilization review process uncovers opportunities to improve organizational management, eliminate oversight, and create systemic processes to ensure maximum revenue recovery. Advent Health Partners works as part of your team to complete more utilization management reviews, reinforcing your organization’s denial prevention strategy and letting your clinical team do what they do best: patient care.
To discover how Advent Health Partners can increase financial recoveries and operational insights for your hospitals or health system, please connect via the button below.