Complex & Denied Claims – [Cloned #5427]

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.

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

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

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

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

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

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.

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. 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. Our approach includes a detailed review of front and back-end processes, leveraging data analytics to identify patterns and commonalities in denied claims. This meticulous method allows for targeted interventions, minimizing administrative costs and maximizing revenue generation as well as reducing future denials.

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

In the fast-paced world of healthcare, providers are constantly navigating the complexities of billing and insurance denials. 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

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.

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

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

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

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

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

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.

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Legacy Conversion


Legacy conversion refers to the process of moving data, operations, and functionalities from an outdated or inefficient system to a newer, more advanced system. This transition is crucial for several reasons:

  1. Enhanced Efficiency: Modern systems are developed with the latest technologies, offering faster processing times and more intuitive interfaces.

  2. Improved Compliance: New software systems are often designed to comply with current regulations and standards, helping your organization stay compliant.

  3. Better Data Management: Advanced systems provide superior data management capabilities, allowing for more accurate and accessible patient or customer information.

  4. Increased Productivity: With updated features and fewer system downtimes, employees can work more efficiently, significantly boosting productivity.

There are three primary methods of system conversion: direct conversion, phase-in conversion, and parallel conversion.

  • Direct Conversion: This approach involves completely switching from the old system to the new system at once. It’s fast but carries higher risk if the new system fails.

  • Phase-in Conversion: Here, the new system’s features are gradually implemented over time. It reduces risk but can prolong the total time to full implementation.

  • Parallel Conversion: Running both systems simultaneously for a period ensures the new system operates correctly before fully transitioning. It’s the safest method but can be resource-intensive.

Choosing the right method depends on your organization’s risk tolerance, resource availability, and how critical the system is to your daily operations.

AR Clean-Up is a critical component of the legacy conversion process, ensuring that your accounts receivable management doesn’t falter during the transition. It involves:

  • Reviewing and reconciling outstanding accounts receivable.

  • Identifying and correcting any discrepancies.

  • Streamlining collection processes to improve cash flow.

Implementing AR clean-up before, during, and after a legacy conversion helps maintain financial stability and ensures that your organization doesn’t lose track of owed revenues during the transition.

The main challenges of legacy conversion include data loss, system downtime, employee resistance to change, and budget overruns. To mitigate these challenges:

  1. Thorough Planning: Develop a detailed conversion plan that includes risk assessment and mitigation strategies.

  2. Data Backup: Ensure all data is backed up before beginning the conversion process to prevent loss.

  3. Employee Training: Invest in comprehensive training programs to reduce resistance and ease the transition for your staff.

  4. Budget Management: Allocate resources wisely and plan for unforeseen expenses to avoid budget overruns.

Wakefield specializes in legacy conversion and AR Clean-Up, providing tailored solutions to meet your specific needs. Our services include:

  • Expert Planning and Implementation: We offer strategic planning and implementation support to ensure a smooth transition.

  • Custom AR Clean-Up Projects: Our team tailors AR clean-up projects to fit your organization’s unique requirements, improving your cash flow and accounts receivable management.

  • Training and Support: We provide comprehensive training for your employees to help them adapt to the new system quickly and efficiently.

By partnering with Wakefield, you can ensure that your legacy conversion and AR clean-up processes are managed effectively, allowing your staff to focus on learning the new system without fear of reduced collections or financial instability.

Planning, testing, and training are key phases that can affect the overall timeline. Engaging with a professional service like Wakefield can help streamline the process and reduce downtime.