Top Five Hospital Denial - Medassets · misaligned with dates of service Lack of insurance clarity...

misaligned with dates of service

Lack of insurance clarity

Dates of Coverage

can also be carved out, or not covered

Individual Servicescarrier information on file for the patient, or out-of-network providers rendering services to patients in a limited access plan

Out of Date Insurance

Top Five Hospital

Denial

patient information causes a chain of incorrect documentation

The leading cause of denials and write-offs

Miskeyed

Demographic Errors

Eligibility and Incorrect Insurance

of Total Potential Revenue

%16

and documentation

Often caused by

Lack of evidence that the chosen treatment plan was required

poor internalprocesses

increases risk for this type of denial

VagueInformation

Medical Necessity

of Total Potential Revenue

%12

of Total Potential Revenue

%42

mismatched with service rendered

Absence of prior authorization on a claim

Authorized service requirements from payors

Increasingly complex

Authorization Requirement

of Total Potential Revenue

%7

$3,430Estimated authorization costs

per physician per year

#3

#4

Sources

1. Gooch, K. (2016, July 26). 4 ways healthcare organizations can reduce claim denials. Retrieved from Becker's

Hospital CFO:

http://www.beckershospitalreview.com/finance/4-ways-healthcare-organizations-can-reduce-claim-denials.html

2 Gooch, K. (2016, July 26). 4 ways healthcare organizations can reduce claim denials. Retrieved from Becker's

Hospital CFO:

http://www.beckershospitalreview.com/finance/4-ways-healthcare-organizations-can-reduce-claim-denials.html

3 https://morningconsult.com/opinions/ten-steps-reduce-denials-win-appeals-improve-hospital-performance/

4 https://www.slideshare.net/billingparadise/denial-management-services-billingparadise

5 http://www.hcpro.com/PPM-328792-12342/The-coding-managers-role-during-the-audit-process.html

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Reasons

1

3

5

4

2

around medical necessity or authorization

Improper coding

Missing codemodifiers in bundling or

unbundling

Missteps

Coding Errors

of Total Potential Revenue

%4Missing additional codified information

#1

#2

#5

$42,000Demographic Errors

$12,000Medical Necessity

$7,000Authorization Requirement

$4,000Coding Errors

$16,000Eligibility and Incorrect Insurance

- - - -

$19,000REMAINING REIMBURSEMENT

$100,000Potential

Hospital Revenue

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