Payer Denials: A Discussion on Prevention
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In this ever-changing revenue cycle space, it’s important for organizations to remain agile. That said, it’s time to break the mold when it comes to denial prevention efforts. During this presentation, we will review trends and traditional methods used over the years and talk about what works and what methods tend to fall short of the goal. We’ll then talk about taking denial prevention to a higher level using a three-pronged approach: reporting, accountability and training. For reporting, we’ll review the importance of defining a claim denial versus a delay in payment and how this distinction impacts prevention focus areas. Accountability is reinforced using a robust action plan that accomplishes cross departmental buy-in. We’ll focus on what should be included in your action plan, what are realistic timeframes, who should be involved and how to keep ideas fresh.
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Payer Denials: A Discussion on Prevention
- 1. Click to edit Master title style Payer Denials: A Discussion on Prevention hrgpros.com Developed by Megan Smith Executive Director, Quality and Training msmith@hrgpros.com 509.789.6656
- 2. Discussion Topics hrgpros.com Traditional Prevention Methods Value of Denial Reporting Prevention Action Plan: Develop, Maintain, Refresh
- 3. hrgpros.com Average cost to re-work a claim $25.00 Denial rate up 2% in 2020 compared to 2016 86% of denials are avoidable 1 in 4 denied claims cannot be recovered Source: Becker’s Hospital Review, “86% of denials are potentially avoidable: Strategies to better prevent, manage denials”, November 2020; https://www.beckershospitalreview.com/finance/86-of-denials-are-potentially-avoidable- strategies-to-better-prevent-manage-denials.html
- 4. Traditional Methods Department Prevention Meetings • May encourage silos • Not as productive as cross- departmental collaboration Monthly Denial Reports • Seem generic and may not resonate • Expectation may be unclear hrgpros.com
- 5. Traditional Methods Real-time Tools or Automation • Requires training and consistent upkeep • Lack of IT resources • Required Fields or Rules • Edit fatigue • Creative workarounds hrgpros.com
- 6. Review Denial Codes Often • 835 reason and remark (CARC/RARC) mapping • Cash poster using current crosswalk • Payer use of codes • Automated workflows in informatics system hrgpros.com
- 7. hrgpros.com Denial of Payment Payer indicates no payment will be made after review of claim Includes reasons that can be appealed Avoidable Examples: Medical Necessity, No Eligibility, No Auth, Untimely Delay of Payment Final decision pending additional information Typically no appeal needed Unavoidable Examples: Additional Information Needed, Coordination of Benefits, Accident/Incident questionnaire
- 8. Refine What is Reported • Remove replicates or “roll up” multiple denials to most pertinent • Both volume & dollar amount • Minimum 3 month trending – 6 months is best • Capture avoidable/unavoidable • Concise - include graphs, status indicators hrgpros.com
- 9. Department Reports Should be Relatable • Make sure departments understand what they’re looking at • Correlate denied dollars as cost of CT machine, # of FTEs • Denial percentages should be tied to department revenue and overall revenue • Explain any delays in results hrgpros.com
- 10. Consider an Event or All-Day Workshop • Understand the impact • Walk in each others’ shoes • Creates synergy • Increase long term buy-in • All in it together hrgpros.com
- 11. Prepare for the Workshop • Establish denial reporting • Survey departments to gauge level of understanding & enthusiasm • Prepare action plan template/handouts • Determine 1 or 2 top denials for each department involved • Limit workshop to <12 people hrgpros.com
- 12. Workshop Agenda Should Include • Round table opinion /association with denials • Walk through of PFS operational workflow • Review pre-workshop survey • Discuss financial impact – keep it relative to audience • Develop action plan & assign roles/responsibilities hrgpros.com Goal: Department Education and Buy-in
- 13. During the Workshop • Bring in lunch/snacks • Check phones at the door • Dry erase boards / sticky notes • 100% participation • Break often -10 mins • Plan activities that get people moving hrgpros.com
- 14. Action Plan hrgpros.com • Description of action • Responsible party • Priority level (multiple actions) • Due dates • Status indicators • Resources needed • Barriers
- 15. hrgpros.com Do’s • Include stakeholders • Executive sponsor(s) • Take your time • Assign roles & responsibilities • Keep plan updated & visible Don’ts • Develop plan in a silo • Assume acceptance is understanding • Expect to tackle everything in first 30 days
- 16. Keeping the Plan Fresh • Be mindful of daily responsibilities and factor in “fires” • Encourage staff level “cheerleaders” • Schedule Reoccurring Meetings • Keep action plan visible in shared location (SharePoint) • Celebrate wins – not matter how small • All in this together! hrgpros.com
- 17. Action Plan Ideas • Reduce insurance plan choices based on plan ID • Create infographics displayed at registration stations • Cross-departmental committee for changes to payer/plan combinations • Committee for denial reason and remark code actions • Develop quality and training program for billing and registration • Implement SharePoint site for resource documents hrgpros.com
- 18. Root Cause Analysis Monthly cross department review of monthly write-offs • CFO, HIM, Patient Access, Billing Directors, Managers & Supervisors • Walk through accounts in informatics system Review monthly bad debt assignment • Accounts with viable insurance, no payment and no PR reason code Complete case studies • High dollar write off • Aged accounts • Unsuccessful appeals hrgpros.com
- 20. hrgpros.com
Editor's Notes
- Validate denial codes often – make sure you don’t have contractual adjustment codes in there – such as a CO 97 or CO 45. Is your code mapping the most up to date? Chances are if you’re using an 835, you will have to have the reason code available to post the 835, but are codes correctly mapping as denials? Also for 835 processing, you’ll want to regularly check that the payers are using ANSI codes appropriately If you’re posting manually, are cash posters manually choosing denial codes? Are they using an up to date reason code crosswalk when posting proprietary codes to the ANSI standard?
- To maximize your message, make sure each department you’re meeting with fully understands the meaning of the report. Schedule a meeting with department stakeholders to review the reports together. Keeping in mind what’s important to that department, your kick off meeting should include data that will resonate with that particular department. For example, if addressing pre service authorization denials with your advanced imaging department, don’t just show up with an excel report full of numbers
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