A multispecialty clinic located in Manhattan, New York that is a leading provider of healthcare services. It has 10 doctors, 8 Nurse Practitioners, and over 100 employees. The clinic serves over 300 patients per day from its 5 locations and is associated with most of the hospitals in the region. It has a revenue of around $60 million yearly. The clinic consistently struggles with a high denial rate of approximately 12%. In this case study, we’ll further outline the causes and discuss the solutions implemented by Globe Centrix to mitigate this problem.
Challenge:
The denials management process is challenging and requires a lot of resources, especially when writing appeal letters. These letters need thorough research, references, and human judgment. The client wants to improve its denial management process by making the appeal process more efficient.
- High Denial Rate The clinic is experiencing a high rate of claim denials, mainly due to coding errors, incomplete documentation, and lack of prior authorization.
- Manual Processes The denials and appeals processes are mostly manual, causing delays, errors, and more work for the staff.
- Inadequate Tracking A centralized system is missing for tracking denials and appeals, which makes it hard to spot trends and apply focused interventions.
Solution:
The client partners with Globe Centrix to standardize and automate its appeal letter generation process. This partnership ensures that the client’s provider customers can recover every dollar owed to them. The clinic implements several strategies to improve and optimize its denials and appeals processes:
Automated Denial Management System The clinic invests in a strong denials management system that automates the identification, tracking, and resolution of denials.
Enhanced Coding and Documentation Practices The clinic implements ongoing training programs for coding and clinical staff to improve coding accuracy and documentation practices. This helps reduce coding errors and denials related to incomplete or inaccurate documentation.
Prior Authorization Process Improvement The clinic implements a rigorous prior authorization process to ensure all needed authorizations are obtained before services are provided. This helps reduce denials due to missing prior authorization.
Centralized Denials and Appeals Team The clinic has a centralized denials and appeals team that manages all denials and appeals. This team works closely with clinical and coding staff to resolve denials efficiently and prevent future denials.
