HOME » Recovering Denied Payments with Analytics and Outsourcing Case Study

Issues

Even the most efficient healthcare organizations see third-party payers regularly delay and deny claims for patient services. Resolving these denials is an ongoing struggle. Without clarity on why a claim was denied or the expertise to pursue appropriate payment, hospitals may write off significant amounts of needed and expected revenue every year.

Writing off denials, however, is not the only option. Analyzing the nature of these denials provides opportunities to identify solutions for improving…
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Answers

The Trinity Health Revenue Excellence Team worked with Convergent and other external vendors and consultants to adopt an internal process improvement approach that included a revenue cycle outsourcer as a major partner in the initiative. This three-pronged strategy included:

1. Outsourcing to bring added clinical and legal expertise to denied claims and also to help develop the skills and expertise of internal staff
2. Using comprehensive data analytics to identify payment variances, monitor root…
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Outcomes

By outsourcing disputed and aged receivables, using a customized analytics tool, and developing clinical denial-focused task forces, Trinity Health significantly improved its denials management and prevention process and exceeded its goal by reducing denial write-offs by more than $25 million in one year. As a result, initial operational write-offs as a percentage of gross revenue dropped from a baseline of 1.09% to 0.78%—far below the national average of 1.5%, based on Academy research—and placed…
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