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3 tips to take denials management processes to the next level


Although these numbers are common and, most likely, first-hand knowledge among providers, they continue to frustrate medical practices year after year.

By now, these medical payment denial statistics are old news:

·       50-65% of denied claims are never reworked

·       200 million claims are rejected every year

·       90% of denials are avoidable

Although these numbers are common and, most likely, first-hand knowledge among providers, they continue to frustrate medical practices year after year.

That’s why focusing on the last statistic-the 90% that are avoidable-is so important. That’s where the hidden revenue lies. Solving, or at the very least resolving, a good chunk of this issue, is one way to get denials under control.

First, Physician Heal Thyself

The first step is to remove the physician from the day-to-day denials-management process. Physicians around the world are already spending too much time behind a computer screen. A study published in the Annals of Internal Medicine found physicians spend a significant part of their day not treating patients, but instead completing other tasks. These physicians spent approximately 27 percent of their time in face-to-face clinical contact with patients, while spending up to four hours on “desk work” for every one hour treating patients. This study had a somewhat small sample size, but it’s easy to see that as contracting and billing grows more complex, physicians may end up spending even more time with a computer and less with patients.


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Whether the billing experts are members of the practice or external experts, physicians who hand off the denials management process increase the time they can spend with patients, and can improve productivity and boost revenue by allowing experts to take control of the process.

Next: Bringing it all together


Next, Automation for the People

Artificial intelligence (AI) is all over the news today, often classified as a savior to business or the end of the workplace as we know it. The truth, like anything, is somewhere in between. AI, like other technologies, is a tool that can be used to increase productivity and efficiency. For providers, AI’s older sibling, automation, can be used to decrease, or even eliminate, denials.

As a business practice, automation can be used to enhance the provider’s office staff. An automated denials management solution can increase efficiency by allowing staff to focus on other issues that require resolution.


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A well-thought-out automated denials management solution actually starts long before any claim is denied. To whittle away at the 90% of denials that are avoidable, the process should begin early.

Finally, Bring it Together

Attacking denied claims in advance, before they happen, is the objective. This allows providers the opportunity to chip away at that 90%. While there are many ways to impact this number, here are three important tactics to start with:

·       Patient eligibility should be high on the provider check-list, perhaps in the number one spot. Checking patient eligibility in advance ensures that patients have insurance to cover the treatment.

·       The claim itself must be clean: treatment codes, which change over time, must be kept up-to-date. Keeping track of those changes is difficult and time-consuming, but an automated solution has the ability to keep codes updated.

·       No matter how much effort is expended verifying eligibility and checking claims, some will be denied. But even this event has a positive outcome: Practices can understand and identify the common reasons for denials, which will help prevent them in the future. A strong automated denials workflow helps ensure these mistakes don’t reoccur by using repeatable rules to ensure office staff understand the reasons behind denials.

Automating this portion of the revenue cycle management process can provide exceptional value to providers as the process also influences the 50% plus of denied claims that are never resubmitted to payers. The best solutions examine current and retroactive denials to ensure the practice receives all the reimbursement it deserves, which helps ensures providers get on the right side of that 90%.


Kevin Lathrop is president of TriZetto Providers Solutions, which provides revenue cycle management systems to providers.

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