Today’s healthcare environment is more data driven than ever before; driving many groups to work towards capturing performance information within all aspects of the revenue cycle. One area in particular where hospitals and physician groups are focusing is to utilize data analytics to enhance workflows for denial management.
Elements of denial management:
1) Denial management starts with denial mitigation through:
- A robust charge/claim editing process
- Engaging a clearinghouse to streamline payment processing
- Engaging a clearinghouse to streamline claim submission routines by including additional levels of claim editing
- Posting up front payer edits for early detection of provider credentialing, claim formatting or patient identification issues
- Dedicating staff responsible for coordinating the dissemination of payer updates and changes to reimbursement policies
2) Denial Management is most effective when the level of detail is sufficient to provide meaningful, focused feedback to the front end.
- This requires maximizing the utilization of HIPAA-compliant 835 remittance posting; which provides the broadest range of denial detail in a standardized format suitable for trending and analysis.
- Posting both ANSI remark codes, in addition to the more general reason codes, in order to minimize research required for understanding the underlying significance of the rejection (WAITING FOR INFORMATION FROM PATIENT vs. just DOCUMENTATION REQUIRED ), thus enabling the claim in question to be routed more efficiently to the appropriate work queue.
- Refine the level of detail by posting all rejections at the line item (procedure) level required so that meaningful feedback can be provided not only to the appropriate Registration and Credentialing departments but to coding and clinical staff regarding compliance and medical necessity issues.
- The enhanced trending and analysis capabilities referenced above allow methodical feedback which then informs the front end processes and becomes part of the denial mitigation initiative.
3) Goals of denial management
- Eliminate re-work
- Achieve first pass claim acceptance rate of 97% (industry standard)
- Maximize customer satisfaction
4) Carrier Take-backs
- Not often seen as part of the denial management process
- Effectively constitute a retrospective denial of the claim
- Provide opportunity, where appropriate, to reach out to patient for timely resolution of potentially erroneous retroactive terminations of coverage
- Provide opportunity to improve the front end operation regarding other reimbursement (ex., missed surgical discounts) or claim integrity (ex., procedures normally bundled submitted on different claims) issues.