Avoiding lost revenue

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Amy Ostrem, Senior Product Manager, MatrixCare
Amy Ostrem, Senior Product Manager, MatrixCare

Consider how much time is spent each month following up on denied claims. Do you know how much claim denials are costing your facility? Are you keeping up with the regulatory changes and nuances of each managed care payer?

Providers have enough demands on their time without having to chase down denied claims. Avoid lost revenue and improve cash flow with a denial management tool that proactively catches these issues before they occur.

How denial management can help you

Proactive denial management and billing staff action in the initial 24 hours with the first response from the payer is key. Yet, many skilled nursing providers are not equipped with the right tools to respond effectively.

We have created a system to offer visibility to help providers see denied claims, an enhanced workflow for staff to act quickly, and reporting to adjust processing based on payer and reason code. This helps us maintain a claims acceptance rate of over 92% on 350,000 electronically submitted claims each month.

Gaining real-time visibility into denied claims should be a breeze. Summaries in the form of charts and graphical views simplify the complexities of claims status and data, showing the number of claims and corresponding dollar amount that need attention (Figure 1). Further drill down data shows denied claims by denial reason, the number of claims denied, and the dollar amounts represented by those claims. Users can even drill down into the specific claim that caused the initial issue and view the entire user, date/time stamped claim history.


Figure 1.


With one login for all care settings and all payers, we can provides a one-stop shop to identify and resolve denied claims at the claim level. In addition, users can save time by grouping specific payer codes and focus on those with the highest revenue potential first. As seen in Figure 2, graphical views display top denial reason, claim count, and dollar amount.

In this example, they can see claims with the highest revenue impact and lowest count in the registration issue and quickly react to the 6 claims for a total of $19,024. Perhaps the resident's ID was inaccurate or the dates of service on the claim don't match up with the resident's coverage. Our denial management system makes it easy to identify and work those high dollar, quick turnaround situations first.

Figure 2.


Another important aspect of denial management is data analysis and scheduled reporting to trend denial data over time. We recommend focusing on key critical denied claims, denial reasons, payers, or specific individual claims initially.

To further to optimize unique payer mix and complexities:

  • Take the top 5 reasons claims were denied and pair that with the top payers. Focus on those that can be acted on.

  • Make upfront configuration changes so future claims never deny for that same reason.

  • Create a pre-processing list to check specific payers or scenarios before claims are created.  

  • Adjust the denial management process to include prioritized steps and which denied claims to immediately edit and resubmit.

  • Make notes on claims with automated user/date/time stamps; or, choose to assign a difficult claim to a supervisor for assistance.

  • Report on all denied claims but set goals and focus on the number of claims denied by payer or by reason code to encourage billing accuracy and first time claim acceptance rates.


Skilled nursing providers can be losing money each month with inefficient or non-existent denial management strategies. MatrixCare Claims Denial Management can help avoid lost revenue and improve cash flow through exception based workflow.  

Amy Ostrem is a senior product manager at MatrixCare.


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