7 Features You Need in Your Claim Management Software

Oct 31, 2019 | Blog Article

Denied claims are at an all-time high. 5 to 10% of medical claims rejected by insurance companies account for 90% of a practice’s missed revenue opportunities. Add in the rise of value-based care and high-deductible health plans, and it seems bad debt is unbeatable.

But there’s opportunity here.

Only 35% of denied claims are ever reworked and resubmitted. And the cost of resolving denials is steep, with an average of $25 spent per denied claim. Multiply that by 100 denials a month (if you’re lucky), and remediation expenses can easily reach $30,000 annually. 

While you may never have enough staff to remediate every denial, there’s some good news on the horizon: 90% of denied claims are preventable. Yup, you read that right. And thanks to new technologies, there are tools you can put in place to decrease denials and efficiently manage those that do occur. 

Lower the high cost of getting paid.

Many healthcare organizations have devised best practices for the revenue cycle, created processes for coding and billing, and introduced new analytics systems, but denial management remains problematic at best. Quit paying for resources unnecessarily just to get what you’re owed. No more overtime staff hours, third party collectors, or account balance write-offs.

Rather, look for a revenue cycle management vendor that helps you put your denied claims and uncollected payments to bed, once and for all. 

7 Features You Need in Your Claim Management Software:

1. Twofold Navigation. Your vendor should be able to use web bots to navigate payers’ websites and EDI to find the most detailed claim status information available, and then go one step even further to retrieve and normalize that data.

2. Reason Code Logic. Wouldn’t it be great if staff could receive easy-to-understand claim updates with a detailed reason for denial? With a logic engine, you can review, standardize, and catalogue all payer reason codes on a claim to identify what is required, within your HIS and workflow system queue. Which means that your dream just became a reality.

3. Customizable Recheck Logic. Remember those web bots we mentioned earlier? Your vendor should be able to inform them when it’s time to recheck a claim for adjudication based on configurable days (like the routine amount of time a payer takes to adjudicate or the days since a particular status), so claims pending payment fall off the work list, and staff only work claims actually at risk of denial. 

4. Work Queue Routing Logic. A disposition of the claim should be assigned based on the category and status code retrieved from the payer portal, allowing claims to be routed to appropriate work queues. Staff can then become specialized in their work lists  by payer, plan type, or reason for denial. And you get a higher yield per employee. (A win-win if you ask us.)

5. Reminder Date Logic. Your vendor should also assign claims in certain work queues a reminder date depending on what needs to be done with the claim, so staff are alerted when tasks need to be performed, accounts are never overlooked, and work lists are reduced even more.

6. Outbound Documentation. Check to see if your potential vendor’s logic engine can add account notes and send documentation reports to create actionable information for denial remediation and save it directly into your HIS. This allows remediation to be performed faster (allowing for an increase in numbers of claims remediated), and staff will get actionable next best actions, making your team of 100 feel like 1000. 

7. Analytics Reporting. Your reports should display summaries of your current and historical data, detailing which trends are most prevalent and allowing you to address issues during the patient financial clearance process, rather than after the claim is submitted.  

The Wrap Up

Denied claims may be getting the best of you, but not anymore. With a claims management solution that delivers detailed and timely answers on claims’ status directly inside the systems you use most, you can eliminate technology hassles and streamline your team’s workflow. 

In other words, denials’ and uncollected reimbursements’ time is done. It’s over. This is your time.

See how we’re helping providers remediate denials in the millions with ClaimStatusPlus by Recondo.

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