Claim Denials

High Dollar Denials Are Often The Least Likely To Be Paid.

Post by
Justin Nicols

When it comes to claim denials, healthcare providers want to recoup as much revenue as possible (it is earned revenue, after all). Most providers attack denials by focusing on the ones with higher dollar values. While this is logical, it’s not the best approach.

Running thousands upon thousands of denials through Sift's data science models has shown that many of the denials with the highest dollar value are the least likely to be overturned and paid. There is no correlation between dollar value and payment. Providers recover the most denial dollars and collect faster when they prioritize the *right* denials.

The right denials to prioritize are the ones that are most likely to be overturned (paid) for each individual provider. These denials can be identified using data science -- advanced modeling on denials history, data pulled from 835’s and 837’s. This method pinpoints which denials are most likely to be overturned and why. It also identifies which denials are likely to go unpaid. This is what we at do at Sift to optimize denials management. Our models rank each denial by its likelihood of being resolved. We deliver a daily work order list to providers, highlighting which denials are most valuable and should consume the majority of their resources in working to resolution.

Most providers have no chance of working all their denials. And most providers are working denials with the wrong, high-value, resources. By understanding which denials are unlikely to be recovered, providers are always working on the best opportunities, especially as denials continually grow.

Healthcare claim denials are time-consuming to work and the resources for working them are expensive. Estimates are that it costs providers up to $118 for each denial they work. By working the right denials, providers see the maximum return for their effort and investment, accelerate cash flow and improve the overall efficiency of their revenue cycle.

It’s a logical mistake to approach claims denials resolution with a bigger is better strategy. There is much more to be gained by focusing on the denials that can actually be resolved.

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