Wave Online is a leading provider of Revenue Cycle management services, dedicated to helping healthcare organizations maximize revenue by minimizing claim denials. Claim denials can have a significant financial impact on healthcare providers, leading to millions of dollars in lost revenue annually. Wave Online expertise lies in identifying the root causes of denials, implementing proactive measures to prevent them, and effectively appealing denials to ensure proper reimbursement.

Background

This case study explores how Wave Online teamed up with a group of Orthopaedic practices in Nevada, to significantly reduce their claim denial rate and generate millions of dollars in newfound revenue.

Challenges Faced by the Orthopaedic provider group.

They experienced a growing issue with claim denials, impacting their financial sustainability. Over the past year, their denial rate had reached 78%, resulting in a loss of millions of dollars annually. This financial burden was further exacerbated by the time and resources necessary to appeal denied claims, which often proved unsuccessful.

High rates of claim denials, up to 78%, pose a significant challenge for Orthopaedic providers, leading to substantial revenue loss and administrative burdens. Appeals further complicate matters, with uncertain success rates. This cycle strains financial health and resources. Solutions entail refining billing practices, meticulous documentation, and navigating appeals efficiently.

Wave Online Solution

Wave Online implemented a comprehensive denial management program for Orthopaedic providers to tackle their challenges head-on. The program consisted of several key components:

Root Cause Analysis: Wave Online team conducted a thorough analysis of a representative sample of denied claims to identify the primary reasons for denial. This analysis revealed that 25% of denials were attributed to coding errors, stemming from inaccurate medical coding, often due to the complexity of coding guidelines and frequent updates.

Incomplete documentation: 43% of denials stemmed from missing or incomplete medical records, hindering the payer’s ability to assess the medical necessity of the services provided.

Payer discrepancies: 35% of denials arose from disagreements with the insurance company regarding medical necessity, coding interpretations, or contractual obligations.

Proactive Measures: We implemented regular audits of their coding practices to ensure adherence to the latest coding guidelines and regulations. This involved reviewing a sample of charts and identifying potential coding errors before claim submission.

Thorough Documentation Reviews: Our team collaborated with their clinical staff to improve the quality and completeness of medical documentation. This included standardizing documentation templates, ensuring proper coding of diagnoses and procedures, and ensuring all necessary information was included in the claim submission.

Payer Contract Reviews: We meticulously reviewed their contracts with various insurance providers to identify potential discrepancies or areas of clarification regarding service coverage and coding requirements. This proactive approach helped minimize potential misunderstandings and disputes with payers.

Effective Appeals Process: We established a streamlined process for appealing denied claims. Dedicated specialists with extensive knowledge of medical coding, reimbursement regulations, and payer policies reviewed each denial and developed targeted appeals strategies. This included gathering additional supporting documentation, clarifying coding interpretations, and negotiating with payers on their behalf.

Results

The implementation of Wave Online denial management program yielded significant positive outcomes for our client: