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Tip of the month: Know your denial numbers

Case Management Weekly, February 1, 2006

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Using the most automated format available-ideally the electronic remittance data from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 835 transaction-your organization should be able to answer the following questions definitively:

*  What percentage of our claims are rejected and require rework to be paid? Ideally, this rate is less than 5% of all electronic claims submitted.

*  What percentage of our claims received by the payer are denied? Based on industry data, expect to achieve single-digit denial rates, but do not plan to start there.

*  What is the dollar amount of our denied claims? Quantifying the lost revenue will help get personnel resources committed and maintained to managing this issue.

*  What are our top denial reasons? Are they consistent across payers?

*  What is our appeal rate? How does or should this vary by reason?

*  What is our overturn rate on appeal? Does this vary by type of service?

Source: Patient Finance Weekly, HCPro, Inc

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