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Payment Accuracy Helps Reduce Medicaid Denials by 30% in Just Three Months

Learn how one national payer prevented claims with errors and improved provider satisfaction

Challenge

A large, national payer was experiencing a high volume of Medicaid claims with errors in one state. This caused higher administrative costs as payer staff worked to address the errors with providers. This also meant claims sat in pend status for a longer period of time, driving an uptick in prompt-pay financial penalties.

Solution

 Availity Payment Accuracy is a robust editing engine that sits within Availity’s Intelligent Gateway and evaluates claims before they reach the payer. Claims with errors are returned to the provider with an easy-to-understand explanation, allowing the provider to fix the claim and resubmit 

This payer implemented the Payer Guidelines package, which uses a payer’s own information as a source of content. For this situation, the edits were created to address a claim error triggered by a specific NPI conflict. 

Results

 The payer went live with the Payer Guidelines editing package in February, and by June they had seen an approximately 30% reduction in denials. They were also pleasantly surprised to see an immediate impact on certain common errors. These edits contributed to a reduction in annual penalty fees that represented approximately $500,000 in savings, as well as a reduced administrative rework cost of approximately $6,000/day. 

30%

Denials reduction

$500K

Reduction in penalties

$6K

Daily administrative savings

“One provider told us the edits have allowed them to catch and fix errors quickly versus managing a claim denial that could take weeks. They were very appreciative of this effort. ”

Associate Director of Medicaid Claims and Encounters

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