Denial Management Calls for More Expertise, Survey Says

Paging subject matter experts for denial management.

According to a recent survey from healthcare AI vendor AKASA and the Healthcare Financial Management Association (HFMA), denial management requires the most subject matter experience compared to most other revenue cycle tasks.

AKASA commissioned HFMA to survey chief financial officers and revenue cycle leaders at hospitals and health systems over the summer. The survey fielded over 550 responses to identify which of the 15 revenue cycle tasks required the most subject matter expertise. Respondents could choose up to five of the tasks.

Nearly 79 percent of the responding healthcare financial and revenue cycle leaders said denial management needed the most specialized knowledge. About half of the respondents said coding and prior authorization, respectively.

Other revenue cycle tasks considered in the survey — and presented in descending order by how much they require subject matter expertise — were insurance follow-up, patient cost estimation and price transparency, eligibility and medical necessity checks, underpayments, claim edits, registration, credit balances, charge capture, scheduling, charge reconciliation, claim status, and late charges.

Denial management is not only the revenue cycle task requiring the most subject matter expertise, but a previous ASAKA survey also found the process to be the most time-consuming in the revenue cycle. Prior authorizations also topped the list of the most time-consuming revenue cycle duties.

Providers have seen denial rates increase in recent years, impacting revenue and the quality and accessibility of patient care. While most claim denials are preventable, some denials arise from issues that providers cannot help. In addition to taking up time, denials management is costly and can adversely impact the patient experience.

The latest survey results also point to a staffing problem. Labor shortages, tight labor markets, and other workforce challenges are at the top of hospital CEO concerns this year. Healthcare organizations may not have not only qualified staff but the right size workforce to manage claim denials effectively. Last year, one in four healthcare finance and revenue cycle leaders reported experiencing revenue cycle workforce shortages.

Automation can bridge staffing gaps while improving denial management and other revenue cycle tasks that may not need as much human touch.

Robotic process automation (RPA) has been proven to make time- and expertise-consuming revenue cycle tasks such as scheduling and prior authorizations more efficient. Artificial intelligence (AI) and machine learning can also streamline complex revenue cycle tasks, saving providers time and money.

Leveraging automated solutions for revenue cycle management can reduce repetitive work, such as claim status checks, so staff can focus on the revenue cycle tasks that need subject matter expertise, according to the survey. More sophisticated solutions can also manage both routine and more nuanced tasks to support revenue cycle management teams.