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Jun 22

Sidekick to Superhero: Automating Claims Appeals

Recognizing the Remarkable Sidekick’s at Your Practice

Robin. Jimmy Olsen. Jarvis. Dr. Watson. You may not be familiar with all of them, but every single one is a superhero sidekick. And we all know nothing much gets done in the complicated world of a superhero without an equally remarkable sidekick.

In the medical practice that’s you.

Physician offices rely on highly-trained office staff to ensure claims appeals are managed efficiently. But attempting to appeal denied claims without the right tools is difficult and time-consuming.

Pow! Bam!

That’s what it feels like when a provider claim is denied by a payer. You’ve spent time creating the entry and submitting it to the payer, so a denial can be an unwanted sucker punch to the gut.

Even so, denials are extremely common—the Employee Benefits Security Administration reports 200 million claims are denied every year in the U.S.—and take a considerable amount of time and money to resolve. Five to 10 percent of a practice’s claims are denied, according to the American Academy of Family Physicians (AAFP). Every claim that must be reworked costs the practice $25, according to MGMA.

Investing in a denials identification and automated appeals process—recommended by the AAFP—eliminates the need to inspect each denial individually. The process should use existing payer rules to ensure you understand the reasons behind denials and identify common errors found in submissions. Having this information up-front ensures the same mistakes aren’t made again in the future.

Utilizing a robust claims denial methodology is critical…because 50-65 percent of denied claims are never reworked.

The most effective services use the payer’s required template to automatically generate an appeal letter, which is then sent to payers for consideration. The best services have the ability to look at current and retroactive denials to ensure the practice receives all the reimbursement it deserves, ensuring payment write-offs are a thing of the past.

Be an Iron Man or Wonder Woman

An automated process reduces the amount of time you need to spend on the task, which improves overall practice efficiency and productivity and, importantly, ensures the practice receives its payments.

Utilizing a robust claims denial methodology is critical to the long-term financial success of the provider office because 50-65 percent of denied claims are never reworked, according to the Healthcare Business Management Association. Depending on the size of the practice and the number old claims never re-processed, the provider office may be out tens of thousands of dollars.

So do yourself a favor, automate your denials management workflow and give yourself a promotion. There’s enough room in every provider’s office for more than one superhero.

If you’d like to find out how TriZetto Provider Solutions can help your practice perform better, learn more about Denials and get a $25 gift card for completing a demo.

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