So, how do you create a Closed Loop Denial Prevention Process? It requires a rules engine capable of finding claims that are destined for denial; preferably before they are posted to the PM system so that backend modifications and corrections are not needed and without creating a lag time prior to submission with negative cash flow impact.
With AccelaSMART, White Plume clients use their denials experience and payor communications to proactively set up customized rules. These rules are designed to prevent denials and improve 1st Pass Pay rates (the rate at which claims are paid with the first submission). The customization available within AccelaSMART allows users to set up the specific criterion that applies to their services, coding, master files, providers, region, plans and other details about a specific claim to ensure it will pass the payor’s edits. Think you don’t need that much granularity? Remember, United Healthcare applies over 82,000 rules to adjudicate claims over and above the industry standards. Think about that.
Diagram 1 depicts a Closed Loop Denial Prevention Process, starting with the advent of a new policy or denied claim, building a customized rule to catch conditions that will trigger a denial, enabling the rule for all billers to use and thereby preventing the denial from happening again.
The great thing about a Closed Loop Denial Prevention Process is that it is scalable and uniform across an organization. The process can be applied consistently for each biller, regardless of their experience, skill sets and day-to-day distractions. It improves productivity with workflow designed to minimize errors and streamline corrections. Using a closed loop process significantly reduces the time clinicians spend on getting claims paid and puts process improvement at the right point in the life cycle of a charge.
Ultimately, a Closed Loop Denial Prevention Process improves cash flows and profitability by ensuring claims can be paid as they should be, quickly and completely.