Insurance Claims Analytics Software to Cut Denials and Save Millions

Denials Analytics Software is extensively used by large health systems that operate numerous facilities in various states,manage hundreds of hospital beds, employ tens of thousands of personnel, and deliver care through hundreds of thousands of outpatient appointments. They state that enhanced analytics have enabled them to tackle impressive results, such as significant savings (within less than a year) on both recurring and annualized recurring payments, as a direct result of reduced denials. What actions do these health systems take to attain such results? 

Insurance providers may reject a significant amount of claims, many of which are never filed again, resulting in tens of millions of dollars of losses.

The majority of denials can be resolved and avoided, but only through effective root cause analysis of claim rejections.

The lack of comprehensive analytics tools impacts the organization’s denial rate: the percentage of denials can far exceed best-practice standards. It leads to ongoing financial losses for health systems. It is essential to build advanced data capabilities to detect issues early in the revenue cycle proactively. 

Challenges for Denial Rate Reduction Strategies 

Revenue cycles are complex and changeable for large health systems with numerous facilities. The requirements and billing procedures of physician practices and hospitals within the same healthcare system are unique. Various insurance providers offer diverse policies. All of this can lead to discrepancies in processing claims and cause defects and waste. 

The list of matters is often linked to procedures and technologies. 

Technology Gaps 

• Absence of tools to proactively identify early-stage issues in the revenue cycle to prevent recurring mistakes and enhance cash flow 

• Ineffective use of available technologies and lack of integration between numerous IT systems, leading to challenges in data analysis and unnecessary work duplication 

• Scarce detail in available EHR reports, challenges in generating them, and pinpointing the exact causes of denials 

Process-Related Weaknesses 

• Significant variability in how the staff carries out its duties 
• Imbalanced workload distribution and exhausting manual data input 
• Slow collecting of detailed demographic and insurance data, which is critical at the front end for denial prevention 
• The labor-intensive task of choosing the correct plan registration for complicated cases due to extensive documentation 
• Missed insurance authorizations when patients remain in the hospital beyond the duration of the initial authorization 

Organizational and Communication Issues 

• Insufficient training for clinical and operational leaders on how their performance impacts the overall denial rate. 
• Poor communication between clinical and operational leaders and financial teams, as the financial teams face challenges in creating affordable reports with suggestions. 

Strategic Challenges 

• Inefficiently tackling the entire issue at once, rather than focusing on specific target areas and gaining from gradual improvements. 
• Lack of a comprehensive improvement plan, driven by data, that would engage financial, clinical, and operational teams to resolve the issue 

Features of the Claims Analytics Tools to Reduce Costs 

Healthcare organizations are interested in reducing the denial rate. They adopt claims analytics solutions driven by advanced data warehouse software, which merge data using ETL processes. This approach offers organizations the following capabilities: 

• Developing interactive visualizations for comprehensive data analysis to produce more actionable insights than outdated Excel-based and integrated EHR reports. 
• Examining the denials, pinpointing their underlying causes, and investigating specific issues. 
• Visualizing and analyzing data on denial age and trends over specific time frames, denial types, current procedural terminology codes also known as CPT codes, and insurers, departments, and account classes. 
• Creating a standardized set of indicators to establish a framework for understanding the specific performance improvements expected by all stakeholders and how to gauge them. 

Organizational Measures to Enforce Healthcare Claims Analytics Software 

To attain maximum benefits with the new software, certain organizational actions should be considered. Healthcare systems should focus on the following supporting initiatives: 

• It is better for organizational leaders to lay the foundation for commitment and promote the concept of reducing claim denials. 
• The CEO, CFO, and COO should collaborate to prioritize addressing claim denials, increase awareness of the issue within the organization, and appoint a dedicated individual to lead the initiatives. 
• A healthcare organization can also recruit or train a focused denials analysis team to study denial tendencies, perform root cause analysis, identify trends, and track improvement opportunities over time. 
• It would be helpful for executives to communicate their vision and issues to clinicians and highlight the effect of the revenue cycle on patient experience. Clinicians should understand that the right initial billing reflects their commitment to patient care. 
• Leaders should stop focusing on one-off tasks. It’s more effective to develop a strategy for continuous improvements with regular evaluation, investigation, and the Plan, Do, Check, and Act (PDCA) cycle conduction. 

Benefits from Enforcing Claims Analytics Software 

By using the claims analytics tool, as noted, organizations can achieve the following outcomes: 

• Reaching a goal that aligns with the highest industry benchmark for denial rates 
• Saving millions of dollars directly caused by the decrease in denials 
• Achieving millions of dollars in annualized recurring benefit 
• Tackling ineffective workflows, procedures, and manual data entry through the PDCA method, which aids in identifying root causes and creating and taking effective measures 
• Pinpointing the root causes of claim denials in divisions, where leadership assumes their methods are efficient 
• Implementation of initiatives throughout the organization with alignment and involvement, driven by measurable and clear analytics data 
• Promoting continuous improvements through the involvement of operational leaders. 

How a Healthcare Software Development Company Can Assist 

An outsourcing company like Belitsoft that specializes in healthcare software development assists top healthcare data analytics companies in building robust data operating systems.

For integrated data platforms developed to collect, store, process, and analyze large volumes of data from various sources (Electronic Medical Records, clinic management systems, laboratory systems, financial systems, etc.), the healthcare software development companies:

• Automate data processing workflows (cleansing, standardization, and normalization)
• Configure scalable data warehouses
• Set up and implement analytical tools for creating dashboards, reports, and data visualizations
• Ensure a high level of data security and compliance with healthcare regulations such as HIPAA
• Integrate machine learning and AI into analytics.

They also help build specialized analytical applications like Denials Analytics software for:

• Using customized date filters to examine particular periods 
• Graphing denial trends, including aging buckets and initial and current rates, in diagrams and charts
• Collecting and examining denial causes 
• Emphasizing main denial reports 
• If you are looking for expertise in data analytics, data infrastructure, data platforms, HL7 interfaces, workflow engineering, and development within cloud (AWS, Azure, Google Cloud), hybrid, or on-premises environments, a healthcare software development company like Belitsoft also can serve these needs.