Game Changer for Your Revenue Cycle: Shift the Focus From Denial Management to Denial Prevention to Accelerate RCM Transformation

With industry trends indicating that around 90% of the denials are preventable, providers are trying to augment their efforts to prevent them. It’s certainly prudent and far less costly to invest time and resources in identifying and fixing issues that drive denials rather than managing claims after they’ve been denied.

However, assessing potential denials and resolving them manually is not a scalable, efficient, or accurate process for any health system, especially for health systems dealing with enormous amounts of data. This is where Innovaccer’s Denial Prevention and Recovery Accelerator comes in. With its innovative capabilities in data unification and analytics, providers can effectively target pre-submission pain points to streamline their billing cycle—and improve clinical outcomes and patient experiences.

Since errors in billing can potentially result in delayed payments or even claim denials, an advanced technology, particularly one powered by machine learning, can help identify and close the coding gaps while improving the prospects for a clean claims submission rate.

Let’s take a look at the common challenges providers face prior to submission of claims, and how Innovaccer’s Denial Prevention and Recovery Accelerator addresses them.

1. Lack of Visibility Into Data to Predict Denials

Since the start of the pandemic, denials have risen 11% in the U.S. In addition, nearly 750 new CPT codes have been added, further increasing the volume and complexity of an already complex billing and coding system. Moreover, it’s a challenge for providers to keep a track of payer policies, and constantly evolving rules and regulations.

Innovaccer’s Denial Prevention and Recovery Accelerator offers a robust library of pre-configured policies as per payors (as pre-bill edits), ensuring that all claims go through the library. It also offers alerts on potential denials well in advance of claim submissions. It automatically checks every claim and every line item for any possible denials and provides potential denial reason codes with a provision to automatically fix errors where applicable.

A vast majority of health systems aren’t equipped to use historical denial patterns to build a strong forecast around the attributes for claims that might get denied. However, Innovaccer’s Denial Prevention and Recovery Accelerator can customize denial prediction (pre-bill edits) based on payer policies and historical claims intelligence, identify new patterns, and convert them to pre-bill edits from current denials.

Here’s an example. The worklist below has a list of claims grouped by Type of Edit “CCI.” The solution accurately points out any errors in the claim line item and alerts the issue with the claim, while offering insights into the potential denial code reason that would be received from the insurance company. It then offers solutions with suggestions/recommended fixes.



Here’s a snapshot of how you can add the recommended modifier and validate it to resolve the error:



2. Ensuring Charge Integrity

Charge capture discrepancies can contribute significantly to revenue loss. In cases where charges aren’t captured or billed correctly, a health system might lose revenue or expose itself to potential regulatory consequences. To improve charge integrity, providers need a system in place to review billable charges for coding completeness and accuracy. Up until recently, the charge review process followed by the majority of health systems requires extensive administrative staff and overhead.

Innovaccer’s Denial Prevention and Recovery Accelerator leverages advanced analytics and algorithms to simplify the process by highlighting potentially missed billable charges. This makes it easier to work on charges that should be part of a claim but might have been missed. In addition to obviously helping avoid revenue loss, it has a provision to check coding performance against established industry benchmarks.

Here’s a snapshot of how it offers the charge breakdown for analysis:



3. Transfer DRGs

Transfer DRG underpayments continue to be a common concern for health systems, resulting in a significant revenue loss, particularly when they struggle to spot and rectify errors in the growing claims backlog. Innovaccer’s Denial Prevention and Recovery Accelerator helps reduce these errors by analyzing transfer DRGs, applying rules, and identifying if there are any underpayments.

When anomalies are identified, Denial Prevention and Recovery Accelerator alerts claims based on PACT (Post-Acute Care Transfer) rules for potential underpayments and suggests fixes where applicable.

With claims denials costing health systems $262 billion, technology that can identify and rectify errors that result in denial rates is a compelling answer to reducing revenue leakage and enhancing revenue integrity. By leveraging the Innovaccer Health Cloud’s unified data model and advanced analytics, the Denial Prevention and Recovery Accelerator helps you analyze pre-submission data to diagnose and fix issues at the initial stages, greatly reducing the chances of claim denials in later stages of the revenue cycle—when they are much more costly to fix and end up unreimbursed entirely.



Contact us to learn how you can use our innovative Denial Prevention and Recovery Accelerator to mitigate pre-submission errors in your revenue cycle and get a demo of our data platform.