Denials Management Assessment

It has been reported that some 1 in 5 claims are rejected by health insurers.  Based on hospitals surveys, managed care claims in a “denied state” range between 10-20% of open A/R.  Therefore at any given time, a hospital with $20 million monthly net revenue will have $2-4 million in an open perpetual status of denial. On the other hand, hospitals reported 98% of denied claims are overturned and ultimately paid correctly.  Situations at each hospital are unique – it depends on the individual revenue cycle processes and computer systems, clinical service offerings, payer mix and contract structure.

Denials are refusals to pay as a result of the healthcare organization not adhering to insurance company policies and procedures, or pending receipt of additional information. TCG can help your organization fix root causes and resolve issues preventing payment for services rendered.

Underpayment

• Incorrect payment resulting from pricing inaccuracies or differences in contract interpretation

• Undetected Underpayments

Addition Information Required

Incorrect payment due to incomplete or inaccurate billing

• Charges or codes missing from the bill and are thus never considered for payment

• ER claim pending receipt of medical records

• Drug/implant reimbursement pending receipt of invoice

• Secondary payment pending receipt of primary EOB

Process Breakdown Issues

Elective service was not pre-authorized

• Days, service, or level of care has no concurrent authorization

• Insurer not financially responsible

• Service not covered by health plan

• Charge/procedure should have been bundled

• Untimely submission of claim