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CLAIM DENIALS MANAGEMENT

$262 billion in AR was denied in 2016[1]. Five years later, it's up 23%[2]. We set out to change that.

Whether due to nuanced payer requirements, complex billing scenarios, or plain old human error, there are millions of reasons for a payer to deny a claim. With traditional reporting measures used by EHRs and patient accounting systems alike, it can be difficult to identify the actual cause of a denial. Claim denials management often seems like chaos. But in chaos, there are patterns.

Claim Denials Managment
Healthcare claim with denied service lines

"

    If you watch close, history does nothing but repeat itself.
What we call chaos is just patterns we haven't recognized. What we call random is just patterns we can't decipher.

-Chuck Palahniuk

"

Vague codes returned by payers to explain a denial are often insufficient – claim and remittance data need to be looked at holistically to identify the root cause. With a union of front-end and back-end revenue cycle knowledge, a deep understanding of how workflows impact billing, and an array of advanced statistical models and machine learning methods at our disposal, we find root-causation in your denials that no dashboard will give you.

Information is just one piece of the puzzle. To act on insights and drive real change is an entirely separate endeavor. That's why our team is comprised of experts in the healthcare finance/IT industry. All of our consultants have a robust background in implementing claims & remittance solutions for organizations of all sizes with varying technologies, business requirements, and regulations.

By equipping our industry-expert staff with our advanced data analytics, we deliver actionable business recommendations that will net you higher revenue cycle performance.

Learn more about our process & pricing.

Underpayment Detection

UNDERPAYMENT RESOLUTION

How confident are you that payers are reimbursing every dollar you're owed?

Often when a payer underpays on a procedure or service it is due to a misalignment in the provider's and payer's understanding of contractual obligation, an error in the payer's adjudication system, or simply billing the claim incorrectly. It is estimated that recoverable underpayments total between 2-6 percent of paid claims[3].

Underpayment resolution starts with recognizing when you are being underpaid. With only your claim and remittance data, we utilize machine learning techniques to identify what procedures/services you're being underpaid on - both for professional and institutional claims.

After we partner with you to discern which opportunities are actionable, we assist you with navigating payer-provider channels for appealing unwarranted underpayments. By assembling custom bulk-appeal extracts to your payers' specifications, we save you the time and resources otherwise spent recovering a lost revenue stream. Ultimately, our team of professionals is prepared to handle the nuance of your unique payer-mix to help you resolve underpayments.

Reporting and Data Transparency

REPORTING & DATA TRANSPARENCY

We fill the gaps in back-end revenue cycle reporting for which some vendors don't have a solution.

Our mastery of data analytics is the core of Claim Capital. When combined with our extensive background in revenue cycle management and information technology, you can rest assured knowing we understand the many facets of the revenue cycle and the importance of leveraging data effectively​.

Having previously created suites of custom-analytical tools for healthcare clients, our industry-experts can help derive meaning from any data. Whether you need help following a hunch, or you have simply identified a gap in your current reporting abilities, Claim Capital can help.

With the ability to leverage claim (837), remittance (835), and payer response (277) data, we can build a variety of reports to your specification. As long as the data is included in any of these industry-standard EDI formats, we've got you covered.

References

[1] LaPointe, J. (2021, February 4). $262B of Total Hospital Charges in 2016 Initially Claim Denials. RevCycleIntelligence. https://revcycleintelligence.com/news/262b-of-total-hospital-charges-in-2016-initially-claim-denials.

[2] https://www.changehealthcare.com/. (2020, December 21). Change Healthcare 2020 Denials Index. Change Healthcare. https://info.changehealthcare.com/reduce-denials/denials-index.

[3] Smith, T. (2011, August 9). Identifying and Collecting Underpayments: 7 Ways to Increase Your Success. Becker's Hospital Review. https://www.beckershospitalreview.com/finance/identifying-and-collecting-underpayments-7-ways-to-increase-your-success.html.

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