In-House Denials Analysis

The foundation of any effective denials tracking, reporting, and management system is denials analysis.

"Denials analysis" is the fast, accurate, and thorough review, categorization, and capture of denial information from a document. The source of denial documents can be EOBs, RAs, or non-EOB correspondence. Denials Analysis is the key first step in implementing an effective denials tracking and reporting solution and can be challenging.

In-house denials analysis approaches include the use of posting staff, the use of dedicated staff, and reporting from EDI (Electronic Data Interchange) data.

Each approach has pluses and problems.

Denials Analysis with Posting Staff

At first glance it may seem a natural fit for transactions posting staff to capture denial information at the time of posting. For full tracking and reporting capabilities, additional software is utilized for data entry. Using possibly two user interfaces, posting staff enter transactions information as well as denials information.

There are several problems with this approach:

		Posting staff are generally not trained or experienced in the accurate review of denials, yet experience and standardization are very important requirements for competent analysis. Denials analysis requires significantly more skill than posting.
		It is much more time consuming to thoroughly analyze denials at the same time as posting transactions.The resulting drop in productivity is surprisingly large.
		Correspondence and other documents that are normally not seen by posters will need to be routed to the posters for entry of denials information or accommodated in some other way, or not analyzed at all. For truly effective denials management, this significant source of denials must be analyzed.
		Denials analysis will be a secondary concern for the posters. The transactions posting function will have the higher priority. The resulting substandard quality of denials analysis will negatively impact tracking and reporting with inconsistent, unreliable data.
		The end result, at best, is a relatively low quality posting operation, and a low quality denials analysis implementation. Both posting and denials analysis are best performed as specialized functions by staff dedicated to one or the other.

Denials Analysis with Dedicated Staff

The use of high-quality denials analysis and management software, operated by dedicated, fully-trained, experienced staff, can fill the requirements for reliable reporting and tracking. The problem is cost. It is cost-prohibitive to implement a competent fully-dedicated solution in-house, when it is substantially more cost-effective to utilize the services provided by Healthcare Reports.

Denials Reporting From EDI Data

After analyzing 250,000 denials, we have found that significant denied money is not reported in electronic (835) data.

In addition to a lack of denials information from 835 data, the code sets themselves are limited and cannot provide the level of detail and depth of analysis that is optimal to make a strong impact on denials processing improvements.

Please refer to our denials tracking and EDI article for more information.

In-House Denials Analysis

In-house denials analysis implementations may be cost justifiable for small operations (just a few beds) with a relatively low volume of denials. But for virtually all business offices serving over 200 beds, the services provided by Healthcare Reports will provide the best approach for lowest cost and highest quality.