Prepare Now for ICD-10’s Uptick in Claim Denials

By A.J. Johnson, General Manager of Analytics Solutions, TriZetto Provider Solutions

Operational costs for providers continue to rise while reimbursement rates decline. The transition to ICD-10 is expected to compound this problem with denial rates projected to rise anywhere from 100 to 200 percent.1

Providers can offset these financial challenges by identifying, appealing, and tracking claims that were denied incorrectly. This can seem like an overwhelming task, so focus on harvesting your “lowest hanging fruit” to see a better return on your time investment. Here are two ways to identify which denials will yield the highest return when appealed.

  1. Focus on denials with the highest probability of getting paid. These are denials that you can most easily address, such as denials where information was missing from a field or where coding or data was incorrect due to human error. You can quickly fix this information and resubmit the claim for reimbursement.
  2. Other denials may be out of your control, such as denials due to a service that was never documented or benefit eligibility issues. You won’t be able to convince the payer to pay for undocumented services or change their fee schedule contract, so these denials are not worth your time to appeal. However, to help stop this type of denial from occurring in the future, you should go back and review your eligibility verification process to ensure it is working correctly.

Of all the efforts you put toward ensuring your organization is financially successful, managing denials may be the most critical step – TriZetto Provider Solutions’ commitment to aiding smooth transitions to ICD-10 is reflected in our service contracting. We offer Eyefinity customers access to several tools for analyzing current revenue cycles, collecting outstanding reimbursements, and planning for challenges you may face as a result of ICD-10.

Visit www.eyefinity.com/contactinfo/trizetto to find out how TriZetto Provider Solutions can help you start preparing today.

1 Work group for Electronic Data Interchange, White Paper: ICD-10 Critical Metrics, October 5, 2012

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