Claim Denial Management Services

Root Cause Analysis: How Improper Claim Denial Prevention Can Be Optimized for Less Recurrent Claim Denials

Claim denial feels like an infinite cycle of submission, rejection, and some irrelevant work that leads to resubmission. At Mastermind Healthcare RCM, we believe the solution is to look for prevention rather than mitigation, which is where Root Cause Analysis (RCA) enters the equation.

Instead of dealing with repercussions that denials bring, Root Cause Analysis (RCA) allows one to trace back problems to the source, enabling healthcare practitioners to make changes at critical problem areas. This leads to effective change.

What Is Root Cause Analysis in Denial Management

Root Cause Analysis Integrated Denial Management (RCAIDM) is a methodology that focuses on finding the underlying basis of consistently recurring claim denials. Mastermind Healthcare RCM employ RCA as a process for correcting claims; we go all out in to achieve revenue cycle optimization, which means utilizing all possibilities provided by modern technology to improve an organization’s financial processes.

Consider this: uprooting a plant won't prevent weeds from returning, unless the root is destroyed.

Common Illustration: The Symptom Versus The Actual Problem

The Claim Denial “Claim denied missing referral.” The Root Cause Front-desk personnel lack training regarding referral prerequisite details for specific payers.

We do not merely make a diagnosis and assist the client in modifying processes at the front end to ensure the same problem does not surface again.

Why Mastermind Healthcare RCM Applies RCA?

The following outlines the rationale for having root cause analysis embedded in our denial management system:

Prevention of recurrence of denials and increased revenue loss

Enhanced acceptance rate of claims at first submission

Detection of gaps in workflow and staff training

Reduction in repetitive work as a time-saving measure

Increase in patient trust towards providers as a result of reduced billing errors

Step-by-Step: Mastermind's RCA Method

In managing denial reduction, we use a highly operational root cause analysis method. This is what we do:

Discovery-Concept from the Data Set

We collect the denial report from your billing or clearinghouse system and split them into distinct categories by:

Denial code classification (CARC/RARC)

Provider or facility

Service type

Payer type

This allows for rapid diagnosis of significant denial patterns alongside the volume patterns.

Classify and Assign Tasks by Order of Importance

We sort denials based on eligibility, authorization, or documentation and coding, and set the order of importance based on their financial consequences.

For instance, if 35%of authorization denied requests lacked authorizations, assigning missing authorizations as the top priority is quite logical.

Keep Asking “Why” Until the Root is Found

Utilizing the "5 Whys" method, we penetrate deeper: Denial: Authorization not received Why? The personnel did not know it was compulsory Why? There is no checklist for payers available Why? There are no instructions in the onboarding process.

Solution: Mastermind offers online training and a digital checklist tailored to the specific preferences of each client’s payer mix.

Take Corrective Action

• We help our clients execute the corrective actions.

• Re-education of front desk staff

• Complete task analysis

• customization of EMR/EHR systems

• Revision of policy documents.

 Monitor and Refine Results

Clients are able to see real results over time through the use of dashboards, KPI trackers, and other methods to measure and track the reduction of claim denial.

Case Study: 40% Reduction in Denials Over 60 Days

Multi-specialty clinic which worked with Mastermind Healthcare RCM was brought on board after repeatedly struggling with denials due to lack of authorizations.

RCA Findings

Not having set authorization policies for payers Excessive staff turnover leading to gaps in understanding

Lack of a means to ascertain the recommendations prior to the visit.

Our Resolution:

Developed an electronic checklist within their EHR.

Provided supplementary training materials for custom refresher training.

One individual was appointed to the role of “payer policy lead.”

Outcomes:

There was a 40% reduction in authorization denials.

There was an increase in the first-pass rate from 76% to 89% within two months.

Closing Remarks Mastermind Healthcare RCM

In Mastermind Healthcare RCM, we don’t merely fix billing problems. We prevent them from occurring at all. Conducting a Root Cause Analysis is a vital step in decreasing denials for the long term as well as increasing revenue and improving operations.

If you want to eliminate denials and establish efficient billing systems, we are available to support you.

Let’s Get Started Contact Mastermind Healthcare RCM for a no-obligation assessment of denial patterns and find opportunities for revenue generation.

Get in touch with us by visiting [https://mastermindhealthcare.com/]