Expedite claims processing.
Post charges daily. Insurance companies
place time limits on claims submission
(e.g., 90 days from the date of service).
These deadlines vary by payer. When you
miss the timely filing deadline, the claim is
denied—and you lose your right to appeal.
Posting charges daily helps ensure your
physician practice meets all deadlines for
It’s also important to follow up with payers soon after claims submission to make
sure claims have been received. The most
successful practices follow up with payers
within five days of claims submission.
Zero in on denials by type.
Nine percent of healthcare charges are initially denied, putting
3.3% of a provider’s net patient revenue at risk, one recent
study found. 5 Meanwhile, appeals cost providers roughly $118
per claim, or a total of $8.6 billion in administrative costs each
year, according to the same study.
While the average denials rate is less than 5% on first submission, we’ve seen rates as high as 61% and
as low as 2%. 6 Typically, the biggest percentage of denials is associated with front-end processes such as
patient registration/eligibility ( 23.9%) and authorization/precertification ( 12.4%). 7 But the types of denials
your practice faces could vary significantly from these averages, as well as by payer. It’s one reason why
drilling down into the top reasons for denials and comparing types of denials by payer are critical to optimizing revenue and efficiency.
Focus on potentials for greatest return.
For example, in determining where to center denials
recovery efforts, consider not only the dollar amount of
the claim but also the type of claim. Clinical denials are
typically harder to work than technical denials, but they
also present opportunities for greatest return when successfully appealed.
This is where expert assistance can make a deep dif-
ference in your practice’s ability to successfully appeal
a denied claim. When your organization finds one but
does not have the internal resources to appeal a clinical
denial, seek ways to partner with outside experts, such as
specialists from local health systems or a revenue cycle
partner with deep expertise in denials management for
your specialty. Knowing when to invest in outside expertise
is critical to improving claims acceptance rates and effec-
tively capturing revenue for care and services performed.
If coding issues are the root cause of a high percent-
age of your clinical coding denials, consider adding
coding expertise on the front end to proactively improve
your practice’s clean claims rate. For certain specialties,
such as orthopedics, neurosurgery, and family practice,
having access to certified professional coders—whether
onsite or through a vendor—is critical to keeping up
with coding updates. Support for pain management
coding also is critical, not just because of the complex-
ity of coding but also due to increased scrutiny of pain
management claims as the nation seeks to address the
growing opioid epidemic.
Look for root causes of delays.
Delayed payments take 16. 4 days longer to resolve, on
average, than claims paid on the first pass, one study
found. 4 Uncovering root causes of payment delays is
an important step toward improving cash flow for your
practice. For example, one commercial payer is three
times as likely to delay payment with a “request for
additional medical information,” according to the study.
Understand the most common causes of payment
delays among all payers. This enables your practice to
educate patient financial services staff on strategies
for a smooth submission process. Such efforts not only
optimize your revenue, but also increase patient satisfaction as claim resolution delays impact patients and