RCM Strategies: Shift Left to Prevent Denials Before They Start

As VP of Revenue Cycle Management, maintaining a steady cash flow is crucial to supporting financial operations, funding innovations in care, and ensuring the operational health of your organization. However, claim delays and denials continue to be a significant barrier, often resulting from issues like incomplete data, errors, and an inability to meet payer-specific requirements. Too often, these issues are addressed only after submission, resulting in costly rework, added administrative burden, and delayed reimbursements from payers.

Fortunately, studies show that 86-90% of claim denials can be prevented through proactive measures.¹ As a result, many RCM leaders are embracing a “shift-left” strategy, focusing on identifying and resolving potential claim issues early in the submission process to minimize downstream disruptions. In this blog, we’ll outline three ways your organization can start ‘shifting left’ to help improve cash flow, while reducing inefficiencies and preventing errors that lead to administrative bottlenecks and pesky denials.

1. Implement Robust Pre-Authorization and Eligibility Verification

Investing in automated, real-time eligibility and authorization checks helps avoid claim issues caused by missing coverage details or incomplete prior authorization requirements. By verifying eligibility and authorization requirements before services are rendered, teams can catch potential claim issues early, reducing denials and ensuring compliance with payer requirements. Advanced tools can also notify staff about specific payer requirements, like “same/similar” or state-specific mandates, ensuring claims meet all necessary criteria upfront.

2. Enhance Data Integration and Analytics for Claim Scrubbing

A “shift-left” approach relies on strong data integration and analytics, enabling real-time claim edits and checks before submission. By leveraging analytics and data from past claim denials and using payer feedback, RCM teams can deploy rules-based claim scrubbing that identifies potential errors, such as missing or inaccurate information. This automated validation process reduces the need for manual rework and boosts the chances of first-pass claim acceptance, helping maintain cash flow and reduces denials.

3. Develop Custom Edits and Rules for Early Error Detection

Creating tailored claim edits and rules based on specific payer requirements, past denial patterns, and organizational nuances can help identify potential errors before claims are submitted. By configuring custom rules that address common denial reasons—such as incorrect coding, missing documentation, or authorization errors—RCM leaders can proactively catch and resolve issues at the point of entry. This approach reduces manual effort and costs by helping to prevent denied claims and keeping them cleaner from the start.

The cost-effectiveness becomes evident when comparing the expense of custom edits upfront to the higher costs of managing denials later.. Custom edits cost $8 per claim, compared to $25 for handling a denial.² Additionally, these custom rules can help frontline staff be more aligned with complex payer policies, improving first-pass rates and shortening the revenue cycle.

Real-World Shifting Left: A Case Study in Advanced Claim Editing

Organizations that continue to rely on reactive, legacy RCM processes could pay a significant price in declined revenue, increased labor and administrative costs, and the ongoing erosion of patient volume and satisfaction. As denials continue to climb and payer requirements become more complex, a reactive approach leaves revenue cycle teams constantly in catch-up mode, struggling to correct issues only after claims have been denied. This results in higher operational expenses and disrupts cash flow, impacting both the financial health of the organization and the experience of patients and providers alike.

A proactive, “shift-left” approach, however, transforms this landscape, as demonstrated in our recent case study with Piedmont HealthCare. By leveraging the Automated Custom Edits (ACE) feature within Availity’s end-to-end RCM platform, Availity Essentials Pro™, Piedmont HealthCare successfully transitioned to a front-end-first strategy. Their primary goals were to streamline the creation and management of custom edits and rules and reduce the time and costs tied to managing denials. They used ACE to build automated, custom rules aligned with their unique payer mix, reducing common claim errors before submission. This not only improved their first-pass acceptance rates but also enabled staff to focus on more complex issues rather than repetitive claim rework.

Read the Case Study

About the Author

As a Product Director at Availity, Justin works to bring products and enhancements to market to assist clients with solving revenue cycle management challenges while optimizing operational efficiency. With over a decade at Availity, Justin understands how our solutions and services help clients achieve their revenue cycle management goals. Justin holds a bachelor’s degree from Indiana University Bloomington.