In most cases, payer denials are investigated and resolved through the functionality of Account Workqueues. Traditionally, Account Workqueues are separated by Payer or Payer Financial Class along with an account alpha-split for larger organizations to help manage staff workloads. This type of configuration results in all denials from the same payer qualifying for the same workqueue. While there can be advantages to having a payer-specific focus, this is not always the most efficient or effective way to resolve denials as the staff assigned to these workqueues may have significantly different skillsets and experience levels.
A new Epic design option, based on Owning Area, is now available for HB users which can improve the AR follow-up process and staffing efficiency. Within the Remittance Code masterfile (RMC), it is now possible to assign an Owning Area to each denial code. This allows you to reconfigure your Account Workqueues to group claim denials for follow-up by billing staff based upon their specific expertise, such as authorization, medical necessity, coding for correct reimbursement, attachment required, etc. You may also choose to route some denials to less-skilled, lower-cost staff for resolution allowing your more experienced people to focus on the more complex situations.
Note that you are not required to move all your Account Workqueues to an Owning Area design. Some of our clients have chosen to implement a hybrid approach, creating specific Owning Area workqueues for some denial reasons while leaving others in payer-specific workqueues. This new design feature provides you with the flexibility to mix and match to optimize the skillsets and priorities within your organization.
Here is how to get started (usually takes six to eight weeks to get the first set/group live):
- Review denial codes to determine which denials should be assigned to a specific Owning Area. Epic provides the following Owning Areas as a starter set but you can add others if needed:
- Authorization – Denials related to requests for service
- Registration – Denials related to coverage, eligibility, filing order, and payer errors
- Coding – Denials related to diagnosis, global, or coding errors
- Orders – Denials related to providers and/or provider types who are not able to bill for services under a specific payer
- Data Processing – Denials related to missing documentation, i.e. medical record requests
- Billing – A catch‐all for all other billing and claims follow-up
NOTE: To manage staffing workload, a catch-all billing Account Workqueue can be segmented through the configuration of Payer and/or Financial Class and alpha split if needed
- Update RMC fields based on your design decisions
- Reconfigure Account Workqueues and rules; as a starting point, consider the following naming convention for your Owning Area workqueues:
- HB DENIALS ‐ ALL PAYERS ‐ AUTHORIZATION/REGISTRATION
- HB DENIALS ‐ ALL PAYERS ‐ CODING/ORDERS QUALITY REVIEAW
- HB DENIALS ‐ ALL PAYERS ‐ REQUEST FOR ADDTL DOCUMENTATION
- HB DENIALS ‐ ALL PAYERS ‐ BILLING
- Validate system build, then test, test, and test some more
- Train staff as needed on the new process/workflows and go-live