Claim denials represent a significant challenge that can impede financial performance and operational efficiency. One survey showed the top three reasons for an increase in claim denials were insufficient data analytics (62%), lack of automation in the claims/denial process (61%), and lack of thorough training (46%).  When resources are spread thin for revenue integrity teams, strategic and customized insights are necessary to ensure accurate reimbursement and billing compliance.  6 Claim Denial Reports for Revenue Integrity Teams Reporting is a valuable tool for uncovering claim den ..read more

Denial mitigation strategies can help billing and revenue teams identify areas of the revenue cycle that need improvement while taking steps to reduce the number of denied claims. Healthcare providers are facing constant challenges in navigating the complex web of payor requirements, coding nuances, and regulatory changes. However, with the right approach and technology tools, denial mitigation can be optimized to achieve higher reimbursement rates and improve overall revenue integrity.  Understanding Denial Mitigation Challenges Before diving into strategies, it’s essential to recognize ..read more

A recent article states, “Hospitals and health systems are spending an estimated $19.7 billion per year to fight denied claims.” As we enter the second quarter of 2024, it’s crucial to examine the emerging patterns and shifts in healthcare claim denials, a critical aspect directly impacting patient care and organizational financial health. Here are five areas to observe regarding emerging healthcare claim denial trends. 5 Emerging Claim Denial Trends Rise of Artificial Intelligence (AI) in Claim Denial Management: The integration of AI technologies is revolutionizing the insurance industry w ..read more

In a time where technological advancements and regulatory changes occur at a rapid pace, the role of change management is a strategic area for professionals in the field of healthcare.  What does change management look like in 2024? One of the most notable questions around this topic is how to communicate the critical importance of buy-in to organization stakeholders.   Change management is not a new concept, but its significance has grown in recent years as healthcare organizations navigate complex challenges such as shifting regulations, cybersecurity threats, and the increasi ..read more

Revenue integrity is a hot topic amidst numerous reports of mounting reimbursement challenges for professionals in healthcare. Payment denials by Medicare Advantage plans have seen a 56% spike, while commercial payors made headlines in 2023 for a 30% increase in denials across outpatient and inpatient settings.   While challenges around denials and revenue leakage are mounting, so are the number of solutions to navigate them. Here are the quintessential capabilities that define a credible revenue integrity solution, critical for steering healthcare institutions towards sustainable re ..read more

Following the aftermath of the recent cyber-attack on Change Healthcare, which led to the temporary disconnection of numerous customers from their regular data feeds, a renewed interest has emerged in protecting operations and ensuring contingencies are in place.   Business continuity is everything in the aftermath of a cyber-attack. Presently, many healthcare organizations remain in limbo without access to important services, such as claim processing for prescriptions, and daily workflows around auditing and reporting.   Cybersecurity is something that everyone recognizes ..read more

Accuracy and efficiency in billing compliance, revenue integrity, and health information management (HIM)/coding processes have never been more critical. As healthcare professionals navigate the industry’s complexities, more organizations are championing the cause of automating traditionally manual billing audit processes.   At the end of the day, it’s a given that manual processes are no longer best serving the audit process. The mounting amount of payor regulations and scrutiny, combined with complex claim data require a risk-based, and automated approach. The Need for Automation in Hea ..read more

With payor scrutiny at an all-time high and the need to provide excellent patient care, many organizations identify with the challenge of navigating both. While external audits are increasing, the tools for successfully managing them are available! Helping to bring back a healthy balance between patient care and revenue margins is at the forefront of technological innovations. Industry Statistics 2023 Benchmark Data revealed the following headwinds that healthcare organizations are facing with external audits. Payors are heavily investing in AI and machine learning to drive efficiency and retu ..read more

Traditional audit methods, while valuable, are no longer sufficient to navigate the intricate web of payer regulations and the need to optimize financial outcomes. The Evolution of Healthcare Audits Historically, audits in healthcare have often been reactive, responding to identified issues or triggered by compliance concerns. The landscape has evolved, and the industry is now recognizing the necessity of a proactive approach to identify and mitigate potential risks before they escalate. Proactive risk-based audits involve a strategic and systematic evaluation of billing processes, focusing on ..read more

The transition from fee-for-service to value-based care reflects a broader shift towards a more sustainable, efficient, and patient-centered delivery of care– a transition that MDaudit proudly supports through technology and analytics.   In the pursuit of billing compliantly and maximizing value-based care reimbursement, hierarchical condition category (HCC) coding ranks high on the list. The proposed Medicare Advantage 2024 Advance Notice released by the Centers for Medicare and Medicaid Services (CMS) begins implementation this year. While the CMS-HCC model V28 will be phased in over th ..read more