August 4, 2021

Revenue Integrity and Denials: “It takes a village”

Evan Martin

Denials continue to create significant revenue leakage and be a hot topic for both hospitals and physicians even in the middle of a pandemic. Billing requirements continue to change rapidly and are extremely challenging to stay ahead of But even in this challenging environment, the best response is prevention. Having prevention team(s) in place is critical to reduce the risk of revenue leakage and the costs associated with recovery.

In my experience with different organizations, the way they structure denial response team(s), often differ, but do have similar themes. But what I really sought to understand, when discussing this with peers was, what made top performing organizations standout? I was part of a team that stood up a Denials Oversight Council that had a big impact on our denial prevention. Following is a summary or ‘revenue investigation’ on that experience and the impact of expanding a denial management program into a Denials Oversight Council.

Organizations who are starting to have success reducing their denial rates have expanded their denial management teams to include members from beyond the revenue cycle. While Revenue Cycle continues to coordinate the appeals process, the input from the expanded team, or ‘village’, not only makes the content of the appeals more effective but creates a more extensive and comprehensive approach to denial prevention.

The “Village”

– Both Hospital and Professional billing teams include their claims and account follow up specialists as the start of the process, as well as a compliance person

– There is a primary coordinator for each clinical or coding appeal

– Clinical and Operational leaders from the Medical Group, Hospitals, Laboratory, Information Services, Managed Care Contracting, Utilization Management, Business Intelligence, Revenue Cycle, Finance, Clinical Informatic, Providers, Expected Reimbursement ((ER) Underpayment Review) Revenue Integrity, Nurse Audit, CDI (Clinical Documentation Improvement) and more

Meeting Frequency

Establish a meeting cadence that works for your organization and ensures an appropriate amount of time to allow for teams to get the work done and balances accountability so project move forward. Frequency can run Monthly, Semi-Monthly or Quarterly with many newly formedcouncils initially meeting Monthly and then scaling back.

  • set priorities for denial prevention
  • oversight of current project
  • remove barriers

The Work

· The Council set prioities for denial prevention, oversight of current projects and removes barriers if/when they arise

· Teams focus on obtaining additional information from health plans to respond the administrative level denials or request for additional information

· Continue to development and monitor denial metrics

· Co-author clinical and coding level appeals

So, if you’re considering changes to your DM program, in line with the expanded model discussed above, here are some things to think about. Set targets and define metrics (commons targets are denials due to issues with authorization, credentialing, billing, and medical necessity)Establish or follow published Key Performance Metrics (KPIs) to measure success (I encourage you to review the recently published article by the HFMA Claim Integrity Task Force seeks to standardize denial metrics)

Expanding a denials prevention program has proven to be a very effective way to improve the prevention of denials while also improving recoveries. And there appears to be no end in sight with regards to how payers continue to invest in tech solutions and services to identify contractual coverage ‘gray zones’ they can continue to exploit.

In summary, I have seen the positive impact of these ‘expanded’ DM teams and programs.

The HFMA has been partnering with major health systems in developing a united front on how to measure denials. The adoption of these standards by providers could be a game changer in denials prevention. If you would like to learn more about implementing denials prevention teams or taking an interdisciplinary approach, please reach out.

Evan Martin

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