Registered nurses perform several jobs throughout a hospital system, most commonly patient care and coding/billing procedures. So, when a hospital starts losing its nursing staff, several critical departments start lacking needed attention. Hospitals are more likely to assign their remaining nurses to patient care instead of denial management because patient satisfaction is one of the top indicators for measuring quality in healthcare, and hospitals need to make sure it’s a top priority. Unfortunately, staff reallocation can cause a considerable increase in denials leading to a decrease in revenue for the hospital, in addition to the cost the hospital is paying due to nurse turnover.
For over two years, the nation has seen a steep decline of nurses in the workforce, partially due to the worldwide pandemic. Still, the nursing shortage persists and leaves hospitals in a challenging situation.
Organization’s who reallocate to patient care areas is beneficial, although it will likely cost the hospital appropriate reimbursement. According to HFMA, proper nurse staffing improves patient satisfaction and quality of life while decreasing medical errors, patient mortality, hospital readmissions, and patient care costs. With the appropriate skill mix, all of this can reduce patient costs and produce higher operating margins for the hospital. This report directly contrasts the discourse that existed in the 1980s and 90s regarding the relationship between nurses and finance leaders.
“Nurses have a direct impact on quality of care and patient and family satisfaction. It is time to shift the nurse staffing paradigm so that the contributions of nurses to positive patient outcomes are understood, valued, and viewed as a priority investment rather than a discretionary expense,”
– American Nurses Association President Ernest J. Grant, Ph.D., RN, FAAN.
Denial rates were climbing before the pandemic, and now so many denial management systems have, understandably, fallen to the wayside. In February 2021, $3 trillion in total claims were submitted by healthcare organizations, and $262 billion were denied. Each provider, on average, had a total of $5 billion worth of denials, and statistically, up to 65% of these claims will never be resubmitted. These hospitals are potentially losing over $3 billion by not resubmitting denials. Of course, denial management can be difficult for hospitals that are operating at a lower staffing rate. Reallocation of staff can be challenging to balance, especially balancing the staffing crisis and the high rates of nursing burnout. Quality of care is a hospital’s first priority, but there’s still a bottom line. Fortunately, there are solutions for hospitals that may be struggling to improve denial management processes while reallocating nurses to patient care areas.
Outsourcing has become a leading solution for hospitals operating with high staff turnover rates. Hiring third-party billing and coding professionals is generally less expensive than in-house coding and billing staff. Additionally, outsourcing prevents your organization from retraining staff to stay compliant with the ever-changing billing and coding regulations. Third parties also come with their own technology and tested denial management workflows and use them to improve your processes.
Clinical expertise is a key factor in denial management systems. An experienced clinical team can determine the viability of every claim, put together quality appeals, and follow up on claims to ensure appropriate revenue recovery. These teams have specific skills to address underlying causes and provide you with solutions to keep track of your cash flow. Choosing a partner with clinical experience in conjunction with denial management knowledge has a higher likelihood of improving your denial management systems and decreasing your time to money.
A pre-bill, or preauthorization, reviews program will increase the likelihood of clean claim submission. This workflow protects your organization’s revenue integrity system proactively as it prevents back-end denials management and performs case reviews prior to submitting a claim.
Choosing to outsource your revenue integrity system to clinical experts gives your organization peace of mind and allows you to allocate your clinical team to do what they do best.
Healthcare technology has come a long way, and the impact has been valuable to hospitals and health systems in their revenue integrity programs. Customized reporting and proper technology implementation can increase coding efficiency, medical documentation accuracy, and coding compliance. Your revenue integrity partner should provide industry-leading technology to give your denial management system an edge.
How Advent Can Help
Advent Health Partners offers premiere denial recovery and prevention services for your organization. Our team has a highly experienced clinical team to reduce your administrative burden and assist your nursing staff. We become an extension of your team, ready to step into your existing workflow. Advent’s reviews are first-level utilization reviews performed in real-time through EMR access, and in the unlikely case of a denial, Advent defends our work throughout the life of the claim–at no additional cost.
Advent provides strategic business intelligence reporting through the Optics reporting platform. When used in conjunction with denial management data and healthcare expertise, Optics gives clients access to valuable, real-time reporting based on previously inaccessible data. Create intuitive dashboards with Optics’ flexible framework to display all the information needed, paving the way to discovering actionable insights to improve denial management and denial prevention programs. Optics can be accessed from desktop or mobile devices, ultimately allowing one to identify areas of their organization that would benefit from improvement.
To learn more about Advent Health Partners’ technology solutions or denial management and prevention services, schedule a 20-minute solutions consultation with a team member.