Q&A: Claims management and follow-up

Q: How can revenue integrity departments prevent revenue leakage through their claims management process?

A: A structured and efficient claims management process helps ensure that claims are processed and paid in a timely manner. Failure to follow up on unpaid claims or resolve discrepancies in a claim can result in significant revenue leakage. A good measuring stick for claims inefficiencies is to frequently and consistently review your timely filing adjustments. Not getting a claim to a payer on time is essentially providing free services, which no one wants.

However, submitting claims on time is just the first step. Ensure systems are in place to track claims status and follow up with payers to collect outstanding payments. Monitoring and auditing through quality assurance efforts is a great way to identify where you may have people, process, or technology issues. Regularly evaluate the performance of your claims specialists/representatives to determine if they are taking the appropriate action on accounts or if they are simply adding a brief note, transferring the account to another individual, or deferring the account and moving on. Establish quality measures that aim for effective work with the least amount of touches—demonstrating an efficient workforce.

Implement a clear and efficient appeals process for denied claims. Making sure that all claims are thoroughly reviewed and appealed when necessary can reduce revenue loss. In our organization, we have a dedicated team that leads the denials and appeals efforts; within that team, separate groups manage clinical and administrative denials. Clinical denials often require the input of a clinician for a successful appeal, so having physicians and nurses assist with these appeals can assist with getting the denials overturned.

Editor’s note: This answer was excerpted from “Preventing revenue leakage through an effective revenue integrity program,” in the January 2025 issue of the NAHRI Journal. The NAHRI Journal is a quarterly journal featuring in-depth analysis and expert advice and is an exclusive benefit of NAHRI membership. Not a member? Join today.