Claims denial: Is your practice leaving money on the table?

Every practice receives claim denials from payers. But did you realize that as many as 3% to 5% of annual practice revenues can be lost for this reason?* In actual terms that means that a practice with five physicians generating $500,000 annually per physician could lose up to $125,000 each year!

Not to fear. There are many ways that your practice can manage and prevent claim denials more efficiently. Let’s discuss a few.

Set up an action plan
A few steps, such as analyzing payers’ explanation of benefits (EOBs), can help you identify staff training issues or point out issues with specific payers. In a recent MGMA Connexion article, Jeffrey B. Milburn, CMPE, recommends a five-point process for building an effective denial management process.

  1. Scan your EOBs – Identify which claims are being denied and for which payers
  2. Find the issues – Determine why claims are being denied
  3. Identify your resource – Assign an individual to be responsible for follow up and them with provide necessary training
  4. Learn from the mistakes – Key in on repeated issues and develop staff training/payer negotiations to address them
  5. Set benchmarks – Decide what you hope to gain from this process and use comparative data to quantity your results

For more details on these recommendations, read Mining for gold: Extract revenue from unprocessed claim denials.

Practice management systems
Today’s advanced practice management systems, such as software like Intergy by Sage V4.0, are designed to maximize your bottom line with features that help you prevent claim denials before they ever leave your office.

View Intergy Demo

Claim scrubbing: Claim editing or “scrubbing” tools allow you to ensure claim validity prior to submission. By performing edits on procedure codes, diagnosis codes, medical necessity and more, claim scrubbers can help enhance revenue for the practice.

Claim Tracking: Some systems also allow your practice to query payer systems to check claim status, identify denials and initiate resolutions immediately.

Task management: Software that allows your practice to “save” claims that aren’t ready for processing (for reasons like missing a referring provider’s NPI) can prevent costly claim rejections. They also create a task list of issues to address. Some systems automatically route issues to the appropriate staff member for follow up through workflow tools.

Ready to get started?
The Intergy practice management system includes these claim prevention/denial features and more. If you’re ready to take the next step toward implementing this platinum standard approach in your practice, Sage Software can help. To set up an on-site demonstration or receive additional information about Intergy, please:

* Milburn, Jeffrey B., Mining for gold: Extract revenue from unprocessed claim denials. MGMA Connexion, January 2007,:38-41.