In the past six years, the average healthcare insurance claim denial rate has risen 33%, from 9% to 12% of all claims being denied. Reducing insurance denials is a top priority for the majority of healthcare providers.1 Historically, the U.S. has been one of the most complex healthcare payment systems globally, requiring patients and providers to prove that treatments are necessary for reimbursement purposes. Further complications have ensued with the volume of healthcare reimbursement changes in the last several years. Between 2020 and 2022, there were an estimated 100,000 payor policy changes.2 This system has led to a high level of complexity, requiring dedicated time and money that could be spent elsewhere. A healthcare organization’s net revenue and margins have significant potential for negative impact due to the high percentage of insurance claim denials.
While many of the challenges related to insurance claims existed before the onset of the COVID-19 pandemic—insufficient data analytics, lack of training, etc.—the pandemic, and the Great Resignation that accompanied it, exacerbated the issues. The rise of insurance denials resulted in multiple trends that have negatively impacted healthcare organizations, including:
1. Revenue Cycle Staffing Challenges
While many are aware of the nationwide clinician shortage, revenue cycle departments continue to experience staffing challenges. Staffing and turnover challenges have limited the ability of healthcare organizations to focus on implementing proactive solutions to prevent insurance denials and dedicate resources to manage existing accounts receivables and claims backlog.
2. Insurance Claim Denial & Write-Off Visibility
The majority of existing claims management and patient accounting systems do not provide comprehensive, real-time, actionable reporting to monitor trends of denied claims and write-offs that help identify root cause operational issues and address the problem at its source. Existing system reporting solutions also make it difficult to track staff success and productivity in appealing denied claims. An efficient denials prevention analytics tool has the capability to significantly reduce the number of insurance denials and revenue loss by allowing an organization to implement targeted and effective denial prevention strategies.
3. Regulatory Audit “Denials”
Government audits and programs intended to identify and recover improper government payments continue to create significant work and risk of revenue loss for organizations. These audit reviews are similar to traditional claim insurance “denials” but are typically received after payment through written notice—making trending, tracking, and a successful appeal difficult if the organization does not agree with the decision.
Forvis Mazars Denials Management Monitoring platform will launch on February 15, 2023 and can help you reduce revenue loss and collection re-work costs from insurance denials. This efficient platform provides actionable data that allows for deeper analysis to shape an effective denials prevention strategy.
It is critical to address denials proactively. Our reporting and measuring tools help organizations understand their denials performance, write off expenses, provide a data-informed prevention strategy, and start quickly while remaining versatile and agile.
For questions or to learn more, reach out to a professional at Forvis Mazars.