“Your small investment could decrease clinic denials, increase your bottom line, and leave a lasting positive impression on patients and providers.”
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What if I told you that making a small investment in a specialized team could reduce clinical denials – that might grab your attention. What if I also told you that your small investment could decrease clinical denials, increase your bottom line, and leave lasting positive impressions on patients and providers?
When my son was just one year old, I took him to the emergency department because his eye was swollen shut and red, and he screamed in pain. The providers were great; they diagnosed cellulitis and prescribed antibiotics. Then I got the bill – my insurer denied the claim because it “wasn’t an emergency.” I asked the hospital to send me an itemization of the detailed charges. And what I found out was that they used the wrong diagnosis code and CPT code on the claim.
I asked the hospital to go back and look at the documentation and correct the chart. They re-coded, resubmitted, and my insurer paid the claim. I’m a revenue cycle expert with over 25 years of experience. I’ve been in healthcare all my life. Imagine the layperson or my neighbor receiving the same bill – an incorrect bill they shouldn’t have to pay. Would they know to go through the same steps, or would they plan to spend –a potentially substantial cost to their family with many downstream personal effects, all from a coding error?
This incident left a lasting impression on my experience in that healthcare system, and many of us have similar stories. How can one, two, or even a few errors in the revenue cycle process make it downstream to us? Patients often remember their incorrect billing at a hospital. How often, upon finding out that you work in healthcare, does a family or friend tell you a story about a time a hospital or medical office got ‘something wrong’ on their chart, bill, and so on?
This incident was the starting block in my thinking about restructuring the revenue cycle. What needs to change so the staff isn’t duplicating work, providers receive correct compensation, the patients get the care they need at their insured rate, and the insurance companies will have fewer opportunities to deny claims?
I’m not the only one considering these changes. In a recent study, “three out of four participants indicated that reducing denials is their highest priority. For 70% of those who responded, claim management is more important now than before the pandemic” . A different study showed that denials increased to 11% of all claims in 2022, averaging 110,000 unpaid claims for an average-sized health system . Substantial dollars and potential long-term adverse financial effects on patients are on the table.
What needs to change? My thinking starts with my number one rule (from my engineering background): Control the things you can control. Revenue cycle leaders and hospitals must focus on what they can control: clinical denial teams, contracting feedback loops, processes, and perspectives.
Control Who is on Your Revenue Cycle Management Team
A revenue cycle management team should go beyond your revenue cycle staff and include contract management executives, physicians, and nurses. Best practices should include increased collaboration and coordination between the revenue cycle, clinical, and contracting departments. Additionally, these departments should have the correct number of staff to manage the accounts and the right mix of people: nurses, coders, and billers, with the appropriate training and education. For large healthcare organizations, this should be a centralized team overseeing the entire process of the health system. But what about a smaller practice, a single provider, or even the health system without available resources? Clinical teams should focus on providing care to their patients, not trying to control clinical denials. That’s where Acclara can help. By outsourcing clinical denials to our team, we can help manage clinical denials, allowing clinical teams to invest their most precious resource (their people!) in patient care, not clinical denials.
Control Your Contracting
Many providers need to match the payers’ contract management sophistication level. Bring the contracting team and the revenue cycle team together instead of having them siloed. Healthcare organizations need to get savvier when it comes to contracts and to know the contract terms to the exact letter. By becoming savvier with technology affecting contracting, growing closer to a payer’s sophistication level is a reality.
Control Your Process
Too often, the process failure shows downstream from where it is happening. In many situations, the authorization obtained must be more comprehensive to cover a change or further exploration in a surgical procedure. Your team could follow the current authorization process to the letter and get prior authorization for a procedure to investigate two vessels related to CT scan information. Are they prepared with the correct authorization when the surgeon needs to go beyond the first two vessels? Or when an ACL surgery also requires repair to the meniscus? Or to remove multiple lesions and not just one?
This process is where your billing process needs to return upstream to Patient Access, so the downstream team has the proper authorization and codes to send a correct bill to the payor. Your approach must include room for coordination between all departments: physicians, nursing, coding, and billing to deliver a holistic and properly processed bill.
Identifying root causes and room for improvement is essential to creating a revenue cycle process that eliminates simple errors and fosters communication between the revenue cycle team and the organization, including clinicians and leadership.
Control Your Perspective
We cannot continue to paint all payors as the enemy. Things will always stay the same if this relationship is adversarial. I’ve talked to the teams reviewing claims on the other side, and most want to approach things from a patient-centric perspective. Controlling your view comes from knowing you’ve created teams, processes, and an organization that delivers accurate and complete documentation and claims and continues to put the patient first.
When you take control of your revenue cycle processes, you have a better view of opportunities for improvement, including when and where you can apply automation or when a human touch is required. Healthcare organizations must be willing to integrate currently siloed teams to resolve clinical denials. An organization’s willingness to take a hard look at its process and identify areas for improvement can be the differentiator between costly denials and improved revenue and leaving a positive lasting impression on your teams and patients.
Whitepaper Reissued 3.30.2023
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Meet the Expert
Dave Szandzik is a consultant with Acclara and applies his industrial engineer training to redefine how we think about the revenue cycle, especially when it comes to clinical denials.