Student Dissertation

Agency : Health Insurance; Claims Process; Claims Delay; Turnaround time

Objective : The objective of the study was to find out the turn-around time of the claims payment which will help to find out the delay and denials of the claims by the payers. 1. To determine the turnaround time of claims payment 2. To find the percentage of claims denied by the Payor 3. To find the reasons of claim denials 4. To determine the impact of denials on revenue cycle of the facility.

Background : A strong revenue stream case is made for intelligent outsourcing of hospital denials-up to 20 per cent more effective in reimbursement terms. This study was about the claims delayed and denied claims.

Methodology : This is a Cross sectional Analytical study on Quantitative data pertaining to claims of the patients generated in a US based hospital. The study was conducted over duration of 2 months. The data on claims generated in a particular US based Healthcare Facility over a period of one month was analysed. Sampling procedure used was convenience sampling with a sample size of 171 denied claims from 13 payers. The study was conducted during March-April 2015.

Findings : Denial management affects all the aspects of the revenue cycle that resulted in no or low reimbursement. Analysis showed that the reasons for the denials included incomplete or inaccurate insurance information, lack of pre- certification or prior authorization, not capturing all of the tests or procedures, diagnoses and procedure coding errors or omissions, past filing limits submission of claims, or a denial due to lack of meeting medical necessity.

Recommendations : Best practice is to trend and track the denials at the time of posting the payments. Denials should be tracked by payor, type of denial, and provider. Staff members must be assigned to work denials on a regular basis, daily for a large medical practice. Key to prevention is understanding the root cause first.