5 min read

Make Your Denials Work for You

Featured Image


Your denials are telling you something. Are you listening?

All clearinghouse platforms and EMR’s have reporting and analytics tools that help you measure your claim processing performance. Leveraging those tools and the data can make or break your revenue cycle. Business offices of healthcare organizations must remain ever vigilant to what their data is telling them and employ the appropriate strategies and tactics with an eye towards continuous improvement.

The revenue cycle relationship between patients, payers, and providers is always telling you something – in this article, we are going to talk about how to hear what it is saying.

Most claims processing systems utilize one of two major claims processing strategies.

Clean Claim Rate with Follow-up

The clean claim strategy is best described as a passive strategy. It gets a high percentage of your claims out the door on day one and lets the payer response drive the process. Its claim editing is limited to ensuring that a claim has all the required fields entered (it is clean). If the claim is clean, it gets the claim out the door to the payer and receives the response. Denied claims are received back into the system for manual intervention.

This strategy has a higher denied claim rate which requires more physical touches of claims, the need for more personnel, and adds more timely filing risk.

Denial Prevention 

A more active strategy, denial prevention emphasizes the claim scrubber in combination with effective decision support tools. Its goal is to get more claims paid on the first submission delivering a lower clean claim rate but a higher first pass yield rate. It accomplishes this by stopping and fixing claims before they go to the payer. New edits and change routines are applied to the claim scrubber on a regular basis.

This approach leverages technology through automation and continuous improvement that reduces the number of times a claim is touched and shortens the overall time to payment for your claims.



What strategy are you using in your organization? Are you finding success in focusing on one vs. another?

At efficientC, our systems and processes use a denial prevention strategy. That is why we describe the efficientC platform as a denial prevention system. Our client's success has shown that this approach leads to more claims getting paid faster. With efficientC, all the tools and technologies are in place to implement a denial prevention strategy.

If you are not an efficientC customer, you may still be able to move your organization toward a denial prevention strategy. There are a few key areas to look at to get started:

• Access to system data. Identify what data is accessible to you from your claim processing solution. This could be reports and analytics provided through your EMR or clearinghouse.
• Accessibility and flexibility of your claim scrubber to apply edits and change routines.
• Application of revenue cycle personnel to payer rule analysis.

Set Goals for Success

Goal Settings on Red Puzzle on White Background.

Using your reporting tools, establish a baseline First Pass Yield (claims paid on first submission) rate. To determine your first pass yield rate, you’ll need to be able to match your claims with payer responses (835s). Claims exported and response reports will typically provide the information that you need. Claims that get a paid response on first submission gets you to your first pass yield rate. Once you understand your current baseline first pass yield rate, it is time to start turning the dials on your claim scrubber to get it to peak efficiency.

At efficientC, we set a goal with all our customers to get and keep their first pass yield rate above ninety percent. Based on what your baseline rate is, establish incremental goals over the next 3 to 6 months and work towards achieving those goals.

Once your goals are set, it’s time to get practical. What information can we get out of our system(s) that will allow us to make improvements to our current denial prevention process? Find the reports that define why your claims are denying and begin your analysis. Group similar denials together to identify where there may be an opportunity. Here are a few suggestions on where to focus your efforts: Identifying where an edit is needed, then implement that edit into your claim scrubber.

  • Look at eligibility and coding denials. Is there a training opportunity with the patient access group or your coders? Feedback loops and collaboration between billing, patient access, and coding can make a significant impact.
  • Payer rules are constantly changing. Look at your payer denials. Which payers are creating the most denials? This could be an indicator of a payer rule change that will need to be added to your claim scrubber.

Our Promise

At efficientC, we promise to help our customers get 95% of their claims paid in twenty days or less. For us to achieve our promise, we must take an active approach to denial prevention. We know that if a claim gets denied, there is a 60% chance that claim will get denied again. Why take that risk? When implemented correctly, our customers have seen on average a 15% cash flow improvement and a 40% reduction of denials in sixty days.

Most claim scrubbers have the data you need to be successful. If you are struggling to find the data, reach out to your current vendor/partner and ask for assistance. Chances are, other customers have asked the same question and they can point you in the right direction.

We hope that the information that we have provided today can help you and your organization take steps to implement a denial prevention strategy. It might take some effort to get started but in the long run, it will increase collections and speed up your A/R turnaround. If you need some help getting started, reach out to us at efficientC. We would be happy to provide a free denial analysis. It’s time to make your denials work for you. We are here to help.

You can reach out to efficientC here.

Do not forget to subscribe to Revenue Cycle Matters for healthcare billing best practices and industry tips!

Subscribe to Healthcare Revenue Cycle Blog