What makes a claim complex or likely to be denied?

Complex claims often involve intricate medical procedures, high costs, or unusual treatment protocols that may not align straightforwardly with payer guidelines. Denied claims can result from errors in medical billing, patient registration, coding inaccuracies, or lack of insurance eligibility verification. Enhanced Efficiency: Modern systems are developed with the latest technologies, offering faster processing times and more intuitive interfaces. Improved Compliance: New software systems are often designed to comply with current regulations and standards, helping your organization stay compliant. Better Data Management: Advanced systems provide superior data management capabilities, allowing for more accurate and accessible patient or customer information. Increased Productivity: With updated features and fewer system downtimes, employees can work more efficiently, significantly boosting productivity.

How does Wakefield handle denied claims?

Wakefield employs a comprehensive review process that includes data analytics to identify the root causes of denials, expert medical coding review for accuracy, and attorney-intervention when necessary to appeal unjustly denied claims.

Can Wakefield improve patient satisfaction through its RCM services?

Absolutely. By streamlining billing processes and ensuring accurate billing and timely patient payments, Wakefield reduces patient stress related to billing issues, directly impacting patient satisfaction positively.

What role does technology play in Wakefield's approach to RCM?

Technology, including electronic health records (EHRs) and advanced RCM systems, plays a crucial role in Wakefield’s approach by enabling more efficient patient intake, claims processing, and remittance processing, thereby improving overall financial performance.

How does effective RCM contribute to a healthcare organization's financial stability?

Effective RCM ensures that all aspects of the revenue cycle, from patient access to final payment, are optimized for efficiency and accuracy. This results in increased revenue generation, reduced administrative costs, and improved profit margins, contributing significantly to financial stability.

What strategies does Wakefield employ to optimize revenue generation for healthcare organizations?

Wakefield employs strategies such as accurate medical coding, effective claims submission practices, payer contract management, and patient payment optimization to ensure that healthcare organizations maximize their revenue generation and maintain robust financial health.

Complex & Denied Claims

Our Complex & Denied Claims solutions are designed to enhance your financial performance and streamline your healthcare operation. Wakefield employs a robust strategy to tackle complex and denied claims, starting by focusing on front-end processes, accurate billing, timely manner of claims and appeals processing, and root cause analysis.

Complex Claims Denial Management

Schedule a quick 15-30 minute call with us for a free consultation to determine your healthcare organization’s needs!

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Complex Claims & Denial Management Out-Of-Network: Pre-Payment/Post-Payment Recovery RCM: Coding/Billing/AR Management Complex Claims RCM Extended Services

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Complex Claims - The Wakefield Advantage

Payer reimbursements have decreased year over year, and healthcare providers face challenges in effectively pursuing all the reimbursements owed to them, particularly in the case of Complex Claims.

Complex Claims in healthcare often involve non-traditional payers and require specialized expertise to resolve. Here are examples of these types of claims:

Out-of-State Medicaid Claims

These claims involve patients who have moved out of the state where they initially received Medicaid.

Motor Vehicle Accident Claims

These claims involve patients who have been injured in a motor vehicle accident and are seeking coverage for their medical expenses.

Veterans Affairs Claims

These claims involve veterans who are seeking coverage for their medical expenses through the Department of Veterans Affairs.

Workers’ Compensation Claims

These claims involve workers who have been injured on the job and are seeking coverage for their medical expenses.

Third-Party Liability Claims

These claims involve situations where a third party is responsible for a patient’s injuries.

Out-of-Network Claims

If the services are performed by an out-of-network provider, the payer may deny all or part of the claim or significantly reduce the payment amount.

Each type of complex claim requires different skills, knowledge, and tools to manage effectively. They represent a modest percentage of total revenue but require significant resources to manage. Despite their complexity, effectively managing these claims is crucial for maintaining the financial health of any healthcare organization. Wakefield stands as a beacon of support for healthcare organizations, offering expert complex claims and denial management programs to navigate these challenging waters effectively.

* HFMA staff and volunteers determined that these healthcare business solutions have met specific criteria developed under the HFMA Peer Review process. HFMA does not endorse or guarantee the use of these healthcare business solutions or that any results will be obtained.

Wakefield's Expert Approach to Complex and Denied Claims

Wakefield’s complex and denied claim programs provide hospitals and health systems with a collaborative solution to tackling non-traditional payer issues across multiple disciplines. This can be scaled to meet the needs of and seamlessly integrate with a provider’s current process, propelling organizations towards operational excellence and financial success. We employ a robust strategy, focusing on:

1. Front-end processes
2. Accurate billing
3. Timely manner of claims and appeals processing
4. Root cause analysis

By leveraging data analytics to identify patterns and commonalities in denied claims, we minimize administrative costs and maximize revenue generation as well as prevent and reduce future denials.

Unlock the Full Potential of Your Revenue Cycle with Wakefield's Denial Management

In the intricate landscape of healthcare revenue cycle management, Complex and Denied Claims represent a modest percentage of total revenue—typically ranging between 3-4%.

However, the effort and resources invested to address and resolve these claims are disproportionately higher, often demanding up to five times the number of resources compared to standard claims. This substantial allocation of time and personnel can significantly strain a hospital’s operational capacities. That’s where Wakefield steps in.

Our state-of-the-art Denial Management solution is specifically designed to tackle and prevent the common hurdles that lead to claim denials. Whether you’re dealing with denials based on Financial Class/Payer, such as Commercial or Government, or you need a strategy that addresses a mix of denial reasons, our services are customized to meet your specific needs.

Our dedicated team dives deep into each denied claim, employing their expertise to analyze, rectify, and expedite the appeals and recovery process.

Data-Driven Strategies for Sustainable Healthcare

Discover Wakefield’s cutting-edge Denial Management solution designed to proactively address and prevent future denials for healthcare providers. Our versatile service offering allows customization of scope based on denial type, Financial Class/Payer (Commercial, Government, Managed Medicare, Managed Medicaid, etc.), or a strategic blend of both.

In the quest to improve financial outcomes and mitigate denials, Wakefield integrates advanced technologies such as electronic health records (EHRs) and utilization of modern Revenue Cycle Management systems.

Comprehensive Coverage of Denial Reasons

Wakefield’s Denial Management services cover a wide array of denial reasons, ensuring no stone is left unturned in safeguarding your revenue. From complex payer policies and inadequate communication to timely filing deadlines and coding errors, our team is equipped to handle challenges across the spectrum. By addressing issues like medical necessity denials, authorization problems, and patient centered denials, we ensure a thorough and effective management process that not only recovers lost revenue but also prevents future denials.

Health insurance denials can be categorized into several types based on the reason for denial

Eligibility Issues

The claim may be denied if the patient’s insurance coverage was not active at the time of service or if the patient is not eligible for the services billed.

Missing or Invalid Claims Data

This can include missing patient information, incorrect plan codes, or technical errors like a missing modifier.

Authorization Issues

If prior authorization was not obtained before the service was performed, the claim may be denied.

Non-Covered Services

The claim may be denied if the procedure is not covered by the payer.

Missing Documentation

Lack of necessary documentation to support the services billed can lead to denials.

Patient Centered Denials

These are claims that are denied and require patient involvement. Examples include termination of coverage and accident detail information.

Coordination of Benefits

Claims for patients covered by more than one health plan can result in delays and even denials until the patient’s coordination of benefits are updated.

Additionally, denials can also be categorized as soft denials and hard denials. Soft denials are temporary, and the claim can be resubmitted after correcting the issue. Hard denials are permanent and require an appeal to overturn. Wakefield’s skilled and experienced staff is adept at recognizing the denial type and quick to develop a strategy to overturn it.

Why Choose Wakefield for Complex Claims & Denial Management?

Our Complex Claims and Denial Management solutions come with a plethora of benefits designed to enhance your financial performance and streamline your operation:

Increased collections: Maximize your revenue with our focused recovery efforts.
Ease of Implementation: Typically, in less than sixty days you can feel confident that Wakefield is already making a difference in your AR without having to shift any burden on your existing staff.
Reduced Denials: Proactively address denial reasons, significantly lowering their occurrence.
Excellent customer service: Experience unparalleled support and guidance throughout your journey with us.
Dedicated Client Manager: Have a go-to expert focused on your account’s success.
In-depth Monthly Reporting: Gain valuable insights into your denials and recovery efforts with comprehensive reports.
Notes files for ingestion into Client system: Integrate our findings directly into your system for seamless operational continuity.

Empowering Healthcare Providers

Wakefield redefines the role of a partner in healthcare services by seamlessly integrating administrative and clinical functions. Our adept management of coding and billing processes, root cause analysis and appeals solutions ensure a smooth flow, crucial for the financial health of healthcare facilities.

At Wakefield, we understand the vital role healthcare providers play in our communities. Our goal is to empower your organization by alleviating the administrative burden of denials, allowing you to focus on what matters most—delivering outstanding patient care. With our contingent pricing model, you can access our expert services without upfront costs. Contact us today for a free quote and discover how we can drive your revenue cycle towards greater financial health and operational efficiency.

Become part of the growing number of healthcare providers who have revolutionized their revenue cycle with Wakefield’s Insurance solutions. Let us take the reins on managing and preventing denials, and successfully resolving your complex claims. Together, we can achieve remarkable financial stability and efficiency for you.

As healthcare organizations navigate the complexities of the modern healthcare landscape, Wakefield remains a pivotal ally, ensuring that every healthcare provider can achieve the best possible financial outcome and continue to deliver high-quality care to their patients.

Complex & Denied Claims

Schedule a quick 15-30 minute call with us for a free consultation to determine your healthcare organization’s needs!

Complex Claims - The Wakefield Advantage

Out-of-State Medicaid Claims

Motor Vehicle Accident Claims

Veterans Affairs Claims

Workers’ Compensation Claims

Third-Party Liability Claims

Out-of-Network Claims

Wakefield's Expert Approach to Complex and Denied Claims

Unlock the Full Potential of Your Revenue Cycle with Wakefield's Denial Management

Data-Driven Strategies for Sustainable Healthcare

Comprehensive Coverage of Denial Reasons

Health insurance denials can be categorized into several types based on the reason for denial

Eligibility Issues

Missing or Invalid Claims Data

Authorization Issues

Non-Covered Services

Missing Documentation

Patient Centered Denials

Coordination of Benefits

Why Choose Wakefield for Complex Claims & Denial Management?

Empowering Healthcare Providers

The only stop healthcare providers need when managing their revenue cycle & collections operations.

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Compliance Manager Rebecca Klinger: #CM12552

Compliance Manager Tyler Marsh: #CM12649

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