Denials

Question 1

What are denied claims?

Answer 1

Medical billing claims processed by the Payer but marked as unpayable for patients.

Question 2

What is the significance of M119 remark codes?

Answer 2

They are used for claims denied due to missing/invalid National Drug Code (NDC) inner/outer codes for medications.

Question 3

How many M119 claims do Revenue Cycle Analysts process daily?

Answer 3

16 M119 remark codes daily.

Question 4

What is the challenge faced by the team regarding denied claims?

Answer 4

Significant delays lead to a backlog of unprocessed claims and missed revenue.

Question 5

What is the automation goal in the context of denied claims?

Answer 5

To increase productivity and reduce the time spent on manual processes.

Question 6

What technology is proposed for automation?

Answer 6

UiPath Robot.

Question 7

What is the expected impact of the UiPath Robot on claims processing?

Answer 7

Accelerates claims processing and minimizes claims rework.

Question 8

What are the core RPA capabilities mentioned?

Answer 8

UiPath Technologies.

Question 9

What is the automation complexity level for the proposed solution?

Answer 9

Medium.

Question 10

What is the primary purpose of Denial Management (DM)?

Answer 10

To address claims denied by payers and improve the financial health of healthcare organizations.

Question 11

What are the key steps in the Denial Management process?

Answer 11

Identification, categorization, analysis, and corrective actions for denied claims.

Question 12

What is one of the main goals of Denial Management?

Answer 12

To reduce the number of denied claims and increase the rate of successful appeals.

Question 13

What factors can lead to claims being denied?

Answer 13

• Coding errors * Missing information * Issues with medical necessity.

Question 14

What is the business impact of unresolved denied claims?

Answer 14

Annual loss of $10M on average across US providers.

Question 15

What are the consequences of denied claims on providers?

Answer 15

• Increased days in Accounts Receivable * Increased write-offs * Cost to collect.

Question 16

How much does it cost providers to rework/appeal resolved claims?

Answer 16

$181 per claim.

Question 17

What role does Document Understanding play in the UiPath solution?

Answer 17

It extracts relevant information from denied claims for processing.

Question 18

What are some expected improvements from the UiPath solution?

Answer 18

• Reduce overall claim denial rate * Improve rate of unresolved denied claims.

Question 19

What does the Denials Management process include?

Answer 19

• Analyze & categorize denials * Apply remedial action * Appeal denial * Track status.

Question 20

Fill in the blank: The automation solution aims to minimize claims _______.

Answer 20

rework.

Question 21

True or False: The Denial Management process is often seen as simple and straightforward.

Answer 21

False.

Question 22

What is the role of various departments in the Denial Management process?

Answer 22

Collaboration between billing, coding, and clinical teams is necessary.

Question 23

What is the expected impact on team satisfaction from the automation?

Answer 23

Improves team satisfaction and productivity.

Question 24

What is a potential challenge in the Denial Management process?

Answer 24

Manual processes that are error-prone and costly.

Question 25

What type of claims are primarily affected by the M119 denial reason?

Answer 25

Claims with missing or invalid NDC codes.

Question 26

What is the expected effect on patient experience from improved Denial Management?

Answer 26

Enhanced patient satisfaction by minimizing billing errors.

Question 27

What is the goal of improving the rate of unresolved denied claims?

Answer 27

To reduce the rate from 60% and support the appeal process via automation ## Footnote Improvement metrics to be sourced.

Question 28

What are the three main objectives in denial management?

Answer 28

* Reduce Cycle time & Rework * Improve member & provider experiences * Reduce Overpayments & Fraud

Question 29

What is the estimated case volume per year in the denial management tool?

Answer 29

250,000

Question 30

What is the estimated automation potential in denial management?

Answer 30

90%

Question 31

What is the average processing time for denials before automation?

Answer 31

5.00 minutes

Question 32

What percentage of denials are appealed pre-automation?

Answer 32

35%

Question 33

What is the cost to appeal denied claims pre-automation?

Answer 33

$117

Question 34

What is the average cost per claim to track status pre-automation?

Answer 34

$20

Question 35

How many claims are tracked pre-automation?

Answer 35

125,000

Question 36

What is the total cost of handling appeals pre-automation?

Answer 36

$2,500,000

Question 37

What is the average processing time saved per claim after automation?

Answer 37

4.50 minutes

Question 38

What percentage of denials are appealed after automation?

Answer 38

70.00%

Question 39

What is the total savings from denial management after automation?

Answer 39

$13,393,750

Question 40

What is the financial impact of denied claims on health systems?

Answer 40

$14M

Question 41

How much do providers spend pursuing delays and denials each year?

Answer 41

$20B

Question 42

What is the average cost per claim that providers incur while appealing denials?

Answer 42

~$44

Question 43

How many rounds of reviews are typically needed to go from denial to payment?

Answer 43

3 rounds

Question 44

What is the average duration of each review round with insurers?

Answer 44

45 to 60 days

Question 45

What process is used in denial management?

Answer 45

* Receive Denial * Analyze & Categorize * Apply Remedial Action * Appeal Denial * Track Status

Question 46

What was the increase in revenue for a customer who appealed M119 denials?

Answer 46

$14M

Question 47

Fill in the blank: The average employee full cost per year is ______.

Answer 47

$70,000

Question 48

True or False: Over half of denied claims are eventually paid out if appealed.

Answer 48

True

Question 49

What technology platforms are mentioned for automation opportunities?

Answer 49

Epic, RightFax, OnBase

Question 50

How many denials were processed in two weeks?

Answer 50

37k denials

Question 51

What was the previous time taken per denial before automation?

Answer 51

15 minutes

Question 52

What is the goal of patient automation?

Answer 52

Increase in net revenue

Question 53

What was the annual write-off amount for one customer due to denials?

Answer 53

$15M

Question 54

What is the purpose of UiPath agents in the automation process?

Answer 54

Extract denial codes and begin remediation

Question 55

Fill in the blank: Generative AI will draft an _______ letter using information from the denial.

Answer 55

appeal

Question 56

What is the impact of unprocessed denials on write-offs?

Answer 56

Increased write-offs due to upheld/uncontested denials

Question 57

What is the annual number of claims submitted?

Answer 57

5.4B claims

Question 58

What percentage of claims are denied each year?

Answer 58

11%+

Question 59

What is the total manual labor cost associated with denied claims?

Answer 59

$100B+

Question 60

What is the impact of DSO (Days Sales Outstanding) on cash flow?

Answer 60

16.4 days

Question 61

What is the first step in the denial management process?

Answer 61

Receive Denial

Question 62

What does RPA stand for in the context of automation?

Answer 62

Robotic Process Automation

Question 63

True or False: Automation can completely eliminate the need for human involvement in the denial management process.

Answer 63

False

Question 64

What is the role of Document Understanding in the automation process?

Answer 64

Extract denial codes and patient information

Question 65

What does the GenAI Extractor enable?

Answer 65

Extraction of unstructured data

Question 66

What does the term 'Human-In-The-Loop' refer to?

Answer 66

Human validation and input in the automation process

Question 67

Fill in the blank: The GenAI Extractor greatly reduces the training required for AI/ML model _______.

Answer 67

training

Question 68

What is one of the key pain points in the Index Patient step of denial management?

Answer 68

Manual, document-heavy process

Question 69

What is the benefit of using Unattended Robots in the appeal process?

Answer 69

Complete forms and draft letters

Question 70

What does the term 'traceability' refer to in the automation process?

Answer 70

Logging all process steps by robots

Question 71

What is a significant challenge in the appeal process?

Answer 71

Filling out forms varying by payor

Question 72

What is the purpose of the Action Center in the automation process?

Answer 72

Aggregated review via Human-In-The-Loop

Question 73

What does the acronym DSO stand for?

Answer 73

Days Sales Outstanding

Question 74

What determines medical necessity for a patient?

Answer 74

The patient's primary care provider (PCP) or referring specialist will determine medical necessity based on the patient's medical condition and current clinical guidelines. ## Footnote Medical necessity is critical for insurance coverage and treatment decisions.

Question 75

List the denial categories related to insurance coverage.

Answer 75

* Not Medically Necessary * No Prior Auth * Out-of-Network Services * Billing Errors * Non-Covered Services * Coordination of Benefits Issues * Policy Limitations/Exclusions * Incomplete Documentation * Timely Filing Limitation ## Footnote These categories represent common reasons for insurance claims to be denied.

Question 76

True or False: Medical necessity is solely determined by the insurance company.

Answer 76

False ## Footnote Medical necessity is determined by the patient's PCP or referring specialist, not the insurance company.

Question 77

Fill in the blank: A patient’s medical necessity will be determined based on their medical condition and the most current _______.

Answer 77

[clinical guidelines] ## Footnote Clinical guidelines are essential for ensuring appropriate medical care.

Question 78

What is the role of the primary care provider (PCP) in determining medical necessity?

Answer 78

The PCP assesses the patient's medical condition and applies clinical guidelines to determine if a service is medically necessary. ## Footnote This role is crucial as it directly influences treatment and insurance coverage.