Transforming Health Plan Operations with Digitized Claim Appeals

Appeals in healthcare play a crucial role in safeguarding patient rights, ensuring fairness, and facilitating access to necessary medical care. The Affordable Care Act grants consumers and providers the authority to contest decisions made by health plans after March 23, 2010. This legislation dictates the procedures health plans must follow for initial appeals and outlines the steps providers and consumers can take to seek a review of decisions regarding payment denials. By providing a mechanism to challenge coverage denials or treatment decisions, appeals empower providers to advocate for their patients.

However, the traditional claim appeals process can be challenging for providers. This is due to lengthy timelines, administrative burdens, lack of transparency, inconsistent decisions, limited communication, and resource constraints. Compounding the issue is the lack of clarity on how or where to submit appeals, as different types of claims may require different submission processes. When providers do manage to submit an appeal, it’s typically done by phone, mail, or fax, adding to the administrative burden of an already manual process. Furthermore, the lack of visibility into appeal status post-submission leads to extensive back-and-forth conversations between providers and payers, amplifying frustration and resources for both parties.

Amidst these complexities, the financial ramifications of denied medical claims and the appeal process are significant. In fact, a Fierce Healthcare article reports that over $10 billion in healthcare expenditure was wasted on disputing claims that should have been paid upon submission.¹ In addition to financial ramifications, these issues can lead to delays in care, misunderstandings, and patient dissatisfaction. Addressing these challenges requires streamlining procedures, improving communication, investing in technology solutions, and ensuring sufficient resources are available for all parties involved.

How Availity Can Help

Sitting at the nexus of payer and provider information exchange, Availity^® sees firsthand the challenges that providers and health plans face when trying to navigate the appeals process. That’s why we are excited to announce Availity’s new Claim Appeals Extended feature within Availity Essentials™. Building upon the value of the Claim Appeals application, this new add-on solution enables a payer to grant providers access to view and manage all their appeals submitted to a payer, even if they were submitted through channels outside of Availity Essentials (such as phone, mail, or fax). By automating key workflows in Availity Essentials, providers can easily:

• Initiate/submit appeals for multiple health plans
• Manage appeals and view statuses and results
• Submit supporting appeal documentation

For health plans and providers seeking to simplify appeals and reduce administrative costs, integrating a digital workflow that leverages automation can help alleviate resource strain and reduce the confusion that frequently hampers claim appeals reviews and approvals. Furthermore, incorporating digital workflows enhances communication efficiency, and can yield time savings by alleviating the burden on staff resources for both parties.

By cutting costs tied to paper-based procedures and administrative expenses linked to phone calls between health plans and providers, Availity projects a savings of $2.31 per appeal.² For one million appeals, this could result in annual savings exceeding $2 million. Alongside cost savings, gaining deeper insight into appeal information provides health plans with the opportunity to analyze the data to fuel quality improvement initiatives that could ultimately enhance patient outcomes.

To learn more about Availity’s Claim Appeals and Claim Appeal Extended value-add features, click here.

About the Author

Christina Love serves as the Director of Product Management at Availity. With a goal of simplifying the complexities of healthcare, her mission is to find commonalities between payers and providers to solve problems and reduce redundancies. Christina has extensive product management and marketing experience across industries, including nearly ten years in healthcare technology with a focus on clearinghouse solutions for payers and providers.

Prior to joining Availity, she held various product management and marketing positions at Greenway Health. She earned a Bachelor of Science degree in Business Administration from the University of North Carolina at Greensboro and a Master of Business Administration from Radford University.