Decrease Claim Denials

How To Decrease Denials and Boost Revenue

By David Pontrello, VP, EMS Healthcare Informatics

There are scads of statistics out there about how many medical claims for services rendered are denied or delayed. But here are some stats we think you should pay particular attention to:

  • 90% of all claim denials are preventable. The Advisory Board
  • Up to 40% of denials are caused by basic registration errors—incorrect data entry at the beginning of the patient encounter, during pre-registration, registration, eligibility and verification processes. Becker’s Hospital CFO Report
  • 35% of all denied claims are never corrected or re-submitted to payers. Medical Group Management Association
  • 31% of providers still handle claim denials manually. 2016 HIMSS Analytics Survey

So how much money is being left on the table?


According to the American Hospital Association (AHA), the average automated claim denial from Medicare’s Recovery Audit Program was worth $714 in the second quarter of 2016. If it was a more complex denial, it was worth an average of $5,418 each. That’s an awful lot of money not coming into your organization.


Here are some tips to prevent denials in the first place.


Assess the problem from all directions

As we see above, the front-end is just as important to improve as the back-end of your operations. Audit your own organizational and team processes. Do it with a 360-degree mindset, and you’ll have an accurate roadmap to form goals and priorities meaningful to your specific needs.

Upgrade technology and automation

If you haven’t done so, tap into electronic registration forms that alert you to missing data and point out inconsistencies in patient data entered. Consider automating processes, too, like how you routinely identify and analyze claim denials. Claim denial management solutions, including EMS Healthcare Informatics’ EDI Power Reader, can turn confusing EDI data and delays into easy, intuitive spreadsheets and reporting.

Be proactive, not reactive

The best salesmen and saleswomen in any high-ticket product or service industry never even meet with a prospective client until they’ve pre-qualified the prospect. So why would we do it any differently? You should and can know if a patient is eligible for a service before the doctor or provider begins his or her work. See our related article on batch eligibility requests: Is this Patient Covered

Educate, educate, educate

Invest time in working with your care providers and billing staff to ensure they get it. Wait some time and then educate again. If each member of the team sees and feels how important their individual work is to the health of your organization, you’ll be on your way to success.

If they don’t? You’re in for frustration, more unnecessary claim denials, and an organizational risk you could have avoided — and that not even the best technology enhancements can solve.