Insurance Claims Analytics Software to Save Millions by Reducing Denials

Denials Analytics is widely used for claims denial management by large health systems that operate across dozens of locations in multiple states, serve hundreds of beds, employ tens of thousands of staff, and provide hundreds of thousands of outpatient visits. They report that improved analytics have helped them achieve impressive savings, sometimes within just a few months, in both recurring and annualized recurring benefits as a direct result of denials reduction. What steps do organizations take to achieve such results?

Insurers may deny a high percentage of claims, many of which are never resubmitted, resulting in losses of tens of millions of dollars.

Most denials are recoverable and preventable, but only with proper root cause analysis of claims denials.

Without relevant analytics tools, the percentage of the organization’s denial rate exceeds best practice multiple times, and healthcare systems continue losing money. It’s necessary to develop new data capabilities to proactively identify issues early in the revenue cycle process.

Challenges on the Way to Decreased Denial Rates

Revenue cycles are complicated and variable for large networks with multiple facilities. Billing processes and requirements of hospitals and physician practices within a single healthcare system are peculiar. Different insurance companies offer various policies. All of this can lead to inconsistencies in handling claims and result in defects and waste. 

The list of issues is often related to processes and technologies.

Issues with Technology

• Lack of tools to proactively determine initial issues that appear early in the process of the revenue cycle to avoid repeating errors and improve cash flow 
• Inefficient utilization of the available technologies and absence of interaction between multiple IT systems, which results in difficulties with data analysis and unnecessary duplication of work
• Insufficient detailing of the available EHR reports, difficulties with generating them, and finding precise issues of denials 

Process-Related Challenges

• Wide variation in the way the staff performs its functions  
• Unequal distribution of the workload and tiresome manual data entry
• Low speed of collecting detailed insurance and demographic information that is essential at the front end for preventing denials 
• The time-consuming process of selecting the right plan registration for complex cases due to lengthy documentation
• Missed insurance authorizations when patients stay in the hospital for a period longer than the initial authorization

Organizational and Communication Gaps

• Lack of training among clinical and operational executives about the correlation between their performance and the general denial rate 
• Miscommunication between the financial teams and clinical and operational leaders, as the former struggle with preparing user-friendly reports with clear recommendations

Strategic Weaknesses

• Ineffective embracing the whole problem at a time instead of concentrating on specific target areas and benefiting from incremental improvements 
• Absence of a holistic improvement plan, based on data, that would involve clinical, operational, and financial teams to address the problem. 

Features of the Claims Analytics Solutions to Save Dollars

To decrease the denial rate, healthcare organizations implement claims analytics solutions based on data warehouses in their processes. It provides organizations with the following capabilities:

• Creating visualizations to generate more actionable insights compared to legacy Excel-based and embedded EHR reports
• Analyzing the denials, drilling into their reasons, and exploring peculiar issues
• Visualizing and exploring the information regarding denial trends over certain periods of time, denial age, types, current procedural terminology (CPT) codes, as well as payers, divisions, and account classes
• Developing a standardized set of metrics to create a framework for understanding what exact performance improvements all the stakeholders expect and how to measure them.

Organizational Measures to Implement Claims Analytics

To achieve the best results with the new software, some organizational measures should be taken into consideration. Healthcare systems should pay attention to the following supporting activities:

• It is recommended for organization leaders to prepare the ground for commitment and advocate the idea of reducing denial claims
• The CEO, CFO, and COO should cooperate to make addressing claim denials a top priority, raise awareness about the problem in the organization, and assign a dedicated person to drive the initiatives forward
• An organization could also hire or train a dedicated denials analysis team that will learn denial trends, conduct root cause analysis, determine patterns, and measure opportunities for improvement over time
• It would be beneficial for executives to explain their vision and tasks to clinicians and demonstrate the impact of the revenue cycle on patient experience. Clinicians should realize that proper initial billing demonstrates their caring attitude toward patients 
• Leaders should cease concentrating on one-time tasks. It is better to come up with a strategy for steady improvements with regular assessment and research and iteration of the Plan, Do, Check, and Act (PDCA) steps.

What Benefits to Expect from Implementing Claims Analytics?

By applying the claim analytics tool, as reported, organizations can gain the following results:

• Achieving a target that meets the best industry standard of denial rates
• Saving millions of dollars directly resulted from the reduction of denials 
• Gaining millions of dollars in annualized recurring benefit 
• Addressing inefficient workflows, processes, and manual entry through the PDCA approach that helps identify root causes and develop effective interventions 
• Identification of the root causes of claim denials in departments, where the leadership believed their processes had been effective
• Adoption of the initiatives across the organization with coherence and engagement thanks to visible and measurable analytics data
• Encouraging sustained improvements due to engaging operational leaders.

How Belitsoft Can Help

Belitsoft is an outsourcing company that specializes in healthcare software development. We help top healthcare data analytics companies build robust data operating systems.

For integrated data platforms developed to collect, store, process, and analyze large volumes of data from various sources (Electronic Medical Records, clinic management systems, laboratory systems, financial systems, etc.), we:

• Automate processes for data cleansing, standardization, and normalization.
• Configure scalable data warehouses.
• Set up and implement analytical tools for creating dashboards, reports, and data visualizations.
• Ensure a high level of data security and compliance with healthcare regulations such as HIPAA.
• Integrate machine learning and AI into analytics.

We also help build specialized analytical applications like Claims Analytics to: 

• Filter for dates of interest
• Visualize denial trends, including initial and current rates, and aging buckets in graphs and diagrams
• Aggregate denial reasons
• Demonstrate top denial reports.

If you're looking for expertise in data integration, data infrastructure, data platforms, HL7 interfaces, workflow engineering, AWS development, or data analytics, we are ready to serve your needs. Contact us today to discuss your project needs.