Top Areas for Improved Claim Appeals in Hospitals Second in a Series
Over the last 37 years, we see common areas of opportunity where Hospital can improve collections and reduce claim denials
Deadlines/Matrix: The number and differences in deadlines as to when an appeal must be filed on a denied claim, how many appeals can or must be filed and the names for the appeals are difficult for the most experienced analyst to keep track of and many software programs do not keep track of these deadlines either.
- Oral representations over the phone regarding “fixes” to a claim do not change or waive these deadlines. We see so many claims where a hospital has made repeated follow ups or changes to a claim, often based on conversations with the payer only to find appeal deadlines has expired.
- Consider creating an actual document or spreadsheet, listing each major payer, e.g Medicare, Medicare Advantage, Medicaid, Medicaid Managed Care, Commercial Exchange Products, ERISA deadlines, or your states workers compensation.
- Work noting these deadlines into your process, software’s collector’s notes, or creating automatic rules for assignment either for internal appeal or outsource.
Lastly, compare these deadlines to your dispute resolution provision. For example, if the appeals provisions say you MAY have physician peer review but the dispute provision says you MUST complete ALL administrative remedies, does that include the permissive peer review?