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By: Ehson Afshar, Director of Revenue Cycle\u00a0<\/b><\/p>\n
The importance of a strong denials prevention program cannot be overstated \u2013 not only does it maximize the revenue coming into the organization, but it minimizes the cost associated with working the claim subsequent times for payment.\u00a0 Many organizations require a culture shift from billing claims and dealing with issues on the back-end versus installing process fixes upstream so that the claim only needs to be worked once.<\/span><\/p>\n Installing a comprehensive program requires people, processes, and technology\/reporting across the entire Revenue Cycle.\u00a0 It is a multi-disciplinary initiative built on strong reporting, analytics, and root cause account reviews.\u00a0 It also requires close tracking and oversight to ensure process fixes result in reduced denials.\u00a0 Let\u2019s explore the three crucial dimensions of such a program \u2013 technology\/reporting, process, and people – and the key drivers of success for each.<\/span><\/p>\n Technology\/Reporting<\/b><\/p>\n The first step in creating a program requires knowledge of what is causing denials and the magnitude of each trend.\u00a0 First, reporting must be created from the 835 remit files returned by the payers.\u00a0 Most organizations will deploy a tool to translate the 835 files into readable data files which can then be analyzed.\u00a0 It is also helpful to combine key 835 fields with other account information from the health information system.\u00a0 Recommended key fields would be the following:<\/span><\/p>\n <\/p>\n Additionally, CARC codes should be mapped to a denial type.\u00a0 As not all CARC codes should be considered denials, a deep dive into the codes should be performed to designate denial vs. non-denial.\u00a0 If a code does not withhold payment for a claim, it should not be considered a denial.\u00a0 Codes should then be assigned a category roll-up such as eligibility, authorization, coding, medical necessity, non-covered, additional documentation needed, billing error, timely filing, or credentialing.\u00a0 Each code should also be assigned a \u201cDenial Prevention Owner.\u201d\u00a0 For example, registration denials would be assigned to Patient Access while coding denials would be assigned to HIM\/Coding.\u00a0 Once the reporting is built out, program leaders will be able to easily identify the biggest opportunity areas by reviewing the highest denied amounts and volumes.<\/span><\/p>\n Processes<\/b><\/p>\n After reporting has been built, program leaders need to perform a deep dive into the different CARC codes used by the payers.\u00a0 Leaders should perform root cause analysis on a historical set of data (such as the last 3 months of denials) to understand which payers use which codes and in what manner they use them.\u00a0 Payer usage of CARC codes is not uniform and can vary heavily across geographic regions.\u00a0 Leaders should also strive to understand which CARC codes are controllable or not controllable:<\/span><\/p>\n <\/li>\n<\/ul>\n <\/li>\n<\/ul>\n After designating controllable vs. non-controllable, leaders who are installing internal process fixes will focus on the controllable denials.\u00a0 Uncontrollable denials will be escalated to respective payer contacts through the contracting department or business office.\u00a0 However, the organization may choose to track progress solely on controllable denials as uncontrollable may involve longer-term contractual changes.<\/span><\/p>\n After the initial root-cause account reviews are conducted and top trends are understood, leaders should begin to implement initiatives to reduce denials.\u00a0 For example, account reviews might show that authorizations in the hospital\u2019s cancer department are not being obtained for certain chemotherapy drugs.\u00a0 In this case, educational material should be built to share with the department.\u00a0 Additionally, edits can be placed in the billing scrubber to detect if a certain drug code does not have an associated authorization number.\u00a0\u00a0<\/span><\/p>\n Account reviews should be conducted on a weekly or biweekly basis.\u00a0 These reviews should be focused on the \u201croot cause\u201d of the denial.\u00a0 In other words, what was the furthest upstream process that resulted in the denial?\u00a0 By focusing on the root cause, we can then begin to formulate the process fix to eliminate the denial trend.<\/span><\/p>\n An account log can be hosted on a shared drive with accounts assigned to the respective denials prevention owner\/team.\u00a0 For example, Patient Access would review high dollar denials that fall under their bucket while Case Management would review their own slice of the data.\u00a0 Since there can be hundreds or thousands of denials each week based on the size of the organization, a dollar threshold can be placed to limit reviews over a certain denial amount.\u00a0 Trends across payer or hospital departments should also be investigated and researched.<\/span><\/p>\n Program leaders should utilize reporting after installing process fixes to monitor if denial volumes are reducing.\u00a0 If not, action plans should be reviewed again for process gaps.<\/span><\/p>\n People<\/b><\/p>\n A prevention program requires leadership across the entire Revenue Cycle.\u00a0 First, a program champion should be identified, most likely the CFO as they would understand the crucial benefits of the program and have the organizational sway to remove barriers while pushing priorities forward.\u00a0 Additionally, a Denials Prevention leader should be chosen to provide oversight for the entire program on a day-to-day basis.\u00a0 This could also be the same leader who manages the denials work down team (if a separate team exists).<\/span><\/p>\n Leadership teams from Patient Access, Case Management, HIM\/Coding, Revenue Management, and the Business Office must be involved in the root cause analysis process and installation of process fixes.\u00a0 While the Business Office or a separate Denials Team may work and manage the denials, the <\/span>prevention<\/span> of denials is reliant upon the area of the Revenue Cycle where the root cause originated.\u00a0 Also, the organization\u2019s training team may be involved on an ad hoc basis when new training needs to be rolled out to different departments.\u00a0 For instance, if a major payer changes authorization or medical necessity requirements for certain procedures, then the training department should update existing documents and educate the front-end teams to check these requirements.<\/span><\/p>\n Denials Action Committee meetings should be held weekly or biweekly to report on trends and action plans.\u00a0 These can either be facility-specific if the system has multiple facilities, area-specific (e.g. Case Management only meeting), or a combination of both.\u00a0\u00a0<\/span><\/p>\n Additionally, the contracting department should be involved to inform and consult on payer strategy.\u00a0 For denials that are payer-related, an escalation structure should be developed to push denial trends through contracting and to the respective payer contacts.<\/span><\/p>\n Summary<\/b><\/p>\n Building a strong denials prevention program takes all 3 components to work.\u00a0 Having effective and actionable reporting being analyzed constantly by the right people will ensure that major denial trends are stopped quickly.\u00a0 By developing a culture of denials prevention, the organization will reap both the financial rewards as well as improve the overall health of the Revenue Cycle.\u00a0\u00a0<\/span><\/p>\n <\/p>\n","protected":false},"excerpt":{"rendered":" By: Ehson Afshar, Director of Revenue Cycle\u00a0 The importance of a strong denials prevention program cannot be overstated \u2013 not only does it maximize the revenue coming into the organization, but it minimizes the cost associated with working the claim subsequent times for payment.\u00a0 Many organizations require a culture shift from billing claims and […]<\/p>\n","protected":false},"author":1,"featured_media":8643,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"content-type":"","om_disable_all_campaigns":false,"inline_featured_image":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[9],"tags":[],"acf":[],"yoast_head":"\n\n
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