Upfront edits help a national health plan reduce Medicaid claim denials by 30%

Challenge

A large, national health plan was experiencing a high volume of Medicaid claims with errors in one state. The health plan wanted to reduce the administrative costs of managing these claims, as well as the prompt-pay financial penalties they were incurring. They believed they could accomplish this by identifying and addressing claims with errors prior to receiving them within their system.

Solution

After learning that an internal fix could take up to a year to develop and implement, the plan turned to Availity for a solution. Availity’s Editing Services solution sits in the Intelligent Gateway and evaluates claims before they reach the health plan. When the editing engine flags claims with errors, they are returned to the provider with an easy-to understand explanation.

Availity’s Editing Services team worked with the plan to identify up to 15 edits that could be implemented, focusing on NPI errors and state claim guidelines. While the NPI analysis can be complex, the Availity team simplified the process and kept the project on track. “We were thrilled Availity was able to accommodate this request,” said the plan’s provider connectivity lead.

“We were thrilled Availity was able to accommodate this request”

—Provider Connectivity Lead

Results

The plan went live with the new edits 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, representing approximately $500,000 in savings, as well as a reduced administrative rework cost of approximately $6000/day.

30% REDUCTION in Denials

	Feb 2022	Mar 2022	Apr 2022	May 2022	June 2022
Baseline	12,047	12,047	12,047	12,047	12,047
Medicaid Case Study	12,727	10,072	8,454	8,179	8,473

Over 12K down to 8K

The plan is also receiving positive feedback from providers. “We heard from one provider who said the Availity edits they are seeing have been very helpful,” said the plan’s associate director of Medicaid claims and encounters. “They’ve allowed them to catch and fix errors quickly versus managing a claim denial that could take weeks. They thanked us for this effort

“We heard from one provider who said the Availity edits they are seeing have been very helpful. They’ve allowed them to catch and fix errors quickly versus managing a claim denial that could take weeks. They thanked us for this effort.”

—Associate Director of Medicaid Claims and Encounters

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Upfront edits help a national health plan reduce Medicaid claim denials by 30%

Challenge

Solution

“We were thrilled Availity was able to accommodate this request”

Results

30% REDUCTION in Denials

“We heard from one provider who said the Availity edits they are seeing have been very helpful. They’ve allowed them to catch and fix errors quickly versus managing a claim denial that could take weeks. They thanked us for this effort.”

Learn more about Availity Editing Services

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