Challenge

Providers spend hours working through denials received from their payers, oftentimes without the ability to identify how and why denials are occurring.

Most provider organizations need a system to track denials by payer to better understand which payers are denying which procedures and to help refine their internal processes so the original claim submission includes the proper filing information – all to help prevent denials from occurring.


Scenario

A provider received an Explanation of Benefits (EOB) from their Medicaid payer with a remittance remark code of CO4 with a procedure modifier of 26 or 91. The provider needed to resubmit the service line within a set time period with the additional information in order to be reimbursed. Resolving denials took the provider hours pulling numerous reports from multiple systems to understand the root cause of the denial. Once identified, the provider spent time resubmitting the claim.


Solution

Initial Setup: 15 minutes
Future Inquiries: Minutes vs. Hours
Outcome: Reduction in denials and increased time savings

Leveraging comparative healthcare analytics, the provider created a report identifying all denials by payer for a specific time period. They were able to filter the denials by the CO4 adjustment code with modifiers 26 or 91.

The provider can also use this level of analytics to monitor key data points by a specific time period including:

  • How often are service lines being returned?
  • Is the volume of denials increasing or decreasing over time?
  • Which service lines are impacted by the denials?

The provider can export the service lines from the application so that they can be reviewed and worked on outside of the application.

Download the Track Denials for Specific Payers PDF