Why 835/837 analysis is not enough to solve healthcare revenue cycle denial challenges

‍

The healthcare industry has always been complex, and one of the most significant challenges facing healthcare providers is revenue cycle management. One of the most common issues that healthcare providers face is claim denials, which can be caused by a variety of factors, including coding errors, lack of documentation, and eligibility issues. To address these denials, healthcare providers often rely on the 835/837 analysis, but is this enough?

The 835/837 analysis is a method of identifying and analyzing claims data to determine why claims are being denied. The 835 file is an electronic remittance advice file that provides details about payments and denials, while the 837 file is an electronic claim file that contains the information needed to process a claim. By analyzing these files, healthcare providers can gain insights into why claims are being denied and take steps to address those issues.

However, while the 835/837 analysis can provide valuable insights, it is not enough to solve all of the challenges that healthcare providers face in managing their revenue cycle. Here are some reasons why:

1. Lack of Granularity: The 835/837 analysis is a high-level analysis that provides a broad overview of claims data. While it can identify patterns and trends, it lacks the granularity needed to identify specific issues that are causing denials. This can make it difficult for healthcare providers to identify and address the root cause of denials.
2. Inability to Analyze Non-EDI Claims: The 835/837 analysis is limited to electronic claims data. It cannot analyze paper claims or other non-EDI claims, which can be a significant source of denials for some healthcare providers.
3. Inadequate Reporting: The 835/837 analysis provides a limited set of reports that may not provide the level of detail that healthcare providers need to identify and address denial issues. This can make it challenging to prioritize denials and develop effective strategies for addressing them.
4. Limited Insights into Revenue Cycle Processes: The 835/837 analysis is focused on claims data, but it does not provide insights into other aspects of the revenue cycle, such as patient registration, insurance verification, and prior authorization. These processes can also impact claim denials, and healthcare providers need to understand how they fit into the overall revenue cycle.
5. Failure to Address Root Causes: While the 835/837 analysis can help healthcare providers identify denials, it does not necessarily address the underlying issues that are causing denials. To effectively manage the revenue cycle, healthcare providers need to address these root causes, which may require changes to workflows, processes, and systems.

In conclusion, the 835/837 analysis is a useful tool for healthcare providers to identify and analyze claim denials. However, it is not enough to solve all of the challenges that healthcare providers face in managing their revenue cycle. To effectively manage the revenue cycle, healthcare providers need to take a holistic approach that includes not only claims data but also other aspects of the revenue cycle. By addressing the root causes of denials, healthcare providers can improve their revenue cycle management and achieve better financial outcomes.