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Prevent Denials with Upstream Editing

Proactive claims editing helps avoid denials and boosts provider satisfaction

Executive Summary

Challenge:

Inability to prevent avoidable denials

Solution:

Availity Payment Accuracy

Payer Guidelines Package

Results:

30% reduction in denials

$500,000 in annual savings

$6,000 in savings per day

Client Info

Company: Large National Health Plan

Member Count: 20,000,000

Solution: Payment Accuracy
• Payer Guidelines Package

Background

A leading national health plan faced persistent challenges with Medicaid claims in one state, which often contained errors, resulting in administrative inefficiencies and financial penalties. Data siloes and manual processes contributed to delays and increased costs, frustrating both the health plan and its provider network.

Business Challenge

These challenges are not unique; they reflect a broader industry problem where most claim edits occur only after submission. For this health plan, that reactive approach, and the inability to prevent avoidable denials, was a major driver of its difficulties.

Administrative Burden: Health plan staff spent excessive time contacting providers to resolve the claim issues, which increased operational costs and slowed down payment cycles.

Provider Friction: When claims were denied, providers often endured long wait times just to speak with someone for clarification, adding frustration and administrative burden to an already strained workflow.

Rework Costs: Every avoidable denial meant extra work which drove up daily operating expenses, compounding the financial burden over time.

Prompt-pay Penalties: Delays in clean claim submission resulted in financial penalties.

Solutions

Because the health plan was already on the Availity network, they were able to implement Availity Payment Accuracy, a robust editing engine that evaluates claims before they reach the health plan. Claims with errors are returned directly into the providers workflow with clear, actionable messages, enabling corrections before submission. To solve its challenges, the health plan used edits from the Payer Guidelines Package.

Payer Guidelines Package: The payer implemented the Payer Guidelines Editing Package which uses a payer’s own information as a source of content. For this health plan, the edits were created to address a claim error triggered by a specific National Provider Identifier (NPI) conflict.

“Fixing errors before claims are denied eliminates costly delays that can take weeks to resolve. Providers described the ability to fix errors at submission as a breakthrough that helped strengthen collaboration and trust”.

VP Claims Administration

Results

reduction in Medicaid denials

savings in annual penalty fees

savings per day in rework costs

Conclusion

Within three months of going live, the health plan saw a 30% reduction in Medicaid denials, immediate impact on common errors, and significant financial savings; $500,000 in annual penalty fees and $6,000 per day in reduced rework costs. Providers reported improved satisfaction, noting that edits allowed them to catch and fix errors quickly, avoiding weeks-long denial management. This approach exemplifies how by moving editing upstream, the health plan empowered their providers to take action and drive measurable impact to both stakeholders.

Learn More

To learn more about how Availity can help reduce administrative waste by moving edits early in the claim lifecycle, visit Availity.com.

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