• Timeframe: One quarter
• Number of outpatient claims denied: 325
• Number of outpatient claims resubmitted for payment: 287
• Number of outpatient claims with resolution: 88% total
• Value of claim denials: 7,370,509 (charges)
• Total value of claim appeals: 6,670,907 (charges)

“Axea Solutions came highly recommended for their broad revenue cycle expertise, and knowledge of our various platforms. And, after a site visit, we realized the Axea team was not only a talented group of HIM professionals, but they were also highly knowledgeable in the outpatient setting, which made it a perfect fit.  They were able to integrate themselves and adapt to our processes with ease. The project was conducted efficiently and exceeded our objectives.”  — Director Revenue Cycle

Outpatient Denials: A Case Study
Multi-hospital Organization

Challenge

A multi-hospital healthcare organization found itself unprepared to address an increase in denials for Outpatient Claims. With a primary focus on preventing and resolving Inpatient claim denials, the client was ill-equipped to handle the different facets involved in Outpatient Claim Denials.  

Specific challenges to note –Outpatient denials come in bulk, as the rules can be written in simpler algorithms. They can be more difficult to discern as they are lumped into all other payment comments on remit from the payer.

Approach

The client turned to Axea Solutions to not only address the increase in denials for outpatient procedures but to transform related operations by standardizing processes across the revenue cycle, addressing clinical denials, and improving accuracy.

Axea utilized our team of seasoned revenue cycle experts and coding educators to shift focus from denial management to prevention. We took a multi-layer approach to streamline the client's revenue cycle. Further, we analyzed the data to identify the root causes and focused on improving the clean claim rate through the continual elimination of these root discoveries. This included analyzing the clinical denial trends and concentrating on correcting outstanding denials by sharing continuous feedback with the client to prevent future denials.

Results

Axea addressed the variances, provided recommendations, and applied education tracks specific to related coding and claim issues. During the three-month engagement, we reviewed 325 denied outpatient claims, with an 88% resolution rate, resulting in 287 claims resubmitted. The initial denials were $7,370,509, and claim appeals were valued at $6,670,907.

With focus and resources designated to Inpatient Denials, Outpatient Denials are often overlooked.  we tend to forget about Outpatient Denials; the financial impact is significant and will continue to increase over time. 

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