Navigating Medicare and Insurance Claim Denials
Providers in the specialized domains of HME, DME, Home Health & Hospice, and Infusion, Specialty Pharmacy play a crucial role in delivering essential services within the comfort of patients' homes. Despite their invaluable contributions, they're continually navigating the intricate maze of Medicare and insurance claim denials. Picture this: it's akin to a football team consistently reaching the red zone but frequently missing the final touchdown. When 86% of these potential "scores" transform into missed opportunities, both patient care and the provider's fiscal stability are jeopardized.
Analyzing the Plays
Medicare and Insurance Claim Success Rate: On average, 17% of Medicare and insurance claims submitted by home-based care providers are denied. For some payors, this rate skyrockets to an unsettling 80%.
Efficiency in Submission: Reflective of a football team's successful plays, only 60% of these Medicare and insurance claim submissions yield the desired result more than 80% of the time.
Appeals Process: The appeal of denied claims can be equated to a team's decision to review a questionable call. Data highlights that for every 500 denied claims, merely one is appealed, indicating potential hurdles or strategic choices at play.
The Financial Impact
Examining Change Healthcare’s data:
The Monetary Setback: Every denied Medicare or insurance claim has a financial ripple effect. Specifically, each denial averages a cost of $118, hitting the provider's bottom line hard.
Cumulative Loss: In a broader perspective, these denied claims amass to an eye-watering $8.6B in administrative costs tied to appeals.
Opportunity for Refined Strategy: Bright spots emerge with insights revealing that a whopping 86% of these claim denials are preventable. This signals ample room for strategic fine-tuning.
Leverage Reimbursement with AI-driven Tools & Analytics
With claim denials seeing an annual rise of 10-15%, HME, DME, Home Health & Hospice, and Infusion, Specialty Pharmacy providers need to reconsider their strategies, especially in the evolving post-pandemic healthcare scenario.
Addressing Medicare and insurance claim denials effectively means partnering with reimbursement specialists. These experts, equipped with AI-driven tools and robust analytics, hold the key to reshaping the claims environment for providers, curbing denials, and amplifying returns. The emphasis shifts from volume to precision.
For these specialized home-based care providers, achieving success is akin to football—it relies on a well-versed team updated with the latest regulations and compliance, utilizing AI automation to minimize human errors and claim denials. Addressing the challenge of Medicare and insurance claim denials proactively is paramount. It's high time for providers to pivot, strategize, and secure those touchdowns for a more robust future.
Connect with us today to learn more about how our reimbursement experts can help optimize your revenue cycle management and get paid faster from insurance companies.
Prochant is the only AI-driven reimbursement service provider in the home-based care industry. We deliver focused revenue cycle management (RCM) solutions to healthcare providers with 7 wholly-owned global delivery centers. Our expertise lies in providing end-to-end RCM for home-based care, infusion, and specialty pharmacies, consistently delivering exceptional results to some of the leading healthcare providers in the country. We harness specialized automation technology and deep industry knowledge to streamline the time-consuming and expensive reimbursement process. As a result, we help healthcare providers accelerate their collections, increase revenue, and reduce operational costs while managing risk. Prochant is HITRUST certified, the gold standard for HIPAA security.