From denials to dialogue: 4 steps to smarter provider education

Small errors can add up fast. They often lead to increased claim denials and unnecessary administrative work for both parties. Health plans should aim to educate each provider on what’s driving their denials, how to correct their specific errors and how to avoid similar issues in the future. 

The top causes of denials nationwide include registration and eligibility issues, missing or invalid claim data and authorization and precertification problems.¹

By proactively sharing insights into inaccuracies before claims are submitted, health plans can help providers avoid unnecessary rework and costs.

Most billing errors come from a small subset of providers. On average, only 12% show abnormal billing behaviors compared to their peers.³ Advanced analytics can detect trends and patterns in billing behavior and identify those providers where education will have the greatest impact.

The most effective tools deliver provider-specific coding insights without disrupting provider workflows. By focusing on those who need the most support, health plans can maximize results while minimizing abrasion.

AI and behavioral science are powerful allies in driving change. Once the right providers are identified, health plans should tailor their education efforts to address specific errors and provide actionable guidance. Helping them understand common billing errors in a collaborative, nonconfrontational way will drive the most effective behavior change.

Providers are often understaffed and overburdened, so making participation easy is key. AI tools can be used to determine the best modality for outreach, draft customized letters and increase engagement within provider portals. Engaging providers in multiple ways can help meet them through their preferred channel and ensure no one falls through the cracks.

• Common education topics include unbundling and upcoding, compliance and documentation gaps, and misrepresentation of services.  

• Outreach options range from embedding education into provider workflows, point-of-submission EDI messaging, online classes and direct mail, to high-touch communications like phone calls or on-site boot camps.  

• A targeted, multichannel strategy can lead to a 24% average reduction in total overbilling and less than 1% provider escalation.³

By taking an intelligent approach, health plans can drive meaningful behavioral changes and minimize provider abrasion.

The healthcare landscape is constantly evolving. To stay ahead, health plans must monitor trends that impact provider billing, such as:

• Shifts in coding guidelines 

• Technology adoption 

• Revenue maximization efforts 

• Emerging patterns in denials and abusive billing 

By dedicating resources to strategy management, health plans can keep education programs current, identify new opportunities and ensure best practices for provider engagement.

Investing in provider education is not just about reducing errors, it’s about building trust. When health plans take a proactive and collaborative approach, they can help lower administrative costs and improve provider satisfaction and outcomes.