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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Out of Date Insurance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
ErrorError
Error Error Error
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