Ahead of the marcus evans National Healthcare CFO Summit 2022, read here an interview with Sandra Johnson where she discusses how hospital systems can maximize reimbursement.

1. Interview with: Sandra Johnson,
VP, Revenue Cycle Management,
Emory Healthcare
“We try to predict what causes a denial,
automate processes, and try to ensure
claims are clean before they are
submitted, to capture as much
reimbursement as we can,” said Sandra
Johnson, VP, Revenue Cycle Manage-
ment, Emory Healthcare.
Johnson is a speaker at the marcus
evans National Healthcare CFO
Summit 2022.
What is driving the increase in
denials?
We’re seeing denials based on payer
behavior and complex contracts. It is
not that healthcare systems are
producing incorrect claims, but payers
are having a difficult time programing
their systems to pay us the correct rate.
When an error is identified it can take 6-
12 months for the payer to correct their
system. The payer then has to
reprocess all our claims. Most hospitals
know what causes claims to get denied,
so we try to ensure the claims are clean
before they are submitted, but payers
are having problems processing them
correctly. I would hate to believe that
they are denying claims just to delay
payment.
What methods work best at
preventing and better managing
denials?
In the past, we monitored denials, root
caused them to determine why they
were not paid correctly. We are now
trying to determine what may cause a
denial before the claim is submitted. We
have been monitoring trends for years.
We are now using those trends to make
sure that we correct claims before they
are submitted. We also now have our
systems providing us with our expected
reimbursement based on our contracts.
If the amount we receive is lower than
the expected amount, the claim goes to
the underpayment work queue. We then
work with the payer to understand why
they did not pay us correctly. We are
also using more automation to assist us
with the submission of appeals once
either a denial or underpayment is
identified without human intervention.
How should the revenue cycle team
be positioned in order to capture
revenue from the first instance?
We try to automate as many processes
as possible, automated eligibility,
automated updating of account,
charging based on physician documen-
tation, etc. Checking as many critical
billing elements as possible to prevent
human error. If a doctor orders a CT
scan, either the order will create the
charge or the charge will create based
on the test being resulted. When a
doctor uses smart text, the system
creates the relevant charge to go onto
the account. That helps us prevent
leakages and capture all charges.
What tools can they use to predict
denials better than they currently
do?
Hospitals have started using AI to
predict what could cause denials before
claims are submitted. The AI is built and
educated to point out what may be
denied and why. As hospitals get better
at cleaning up claims, we will reach the
point where everything we submit
should be paid. So if it isn’t paid, we’ll
know its payer behavior or the contract
is not set up in their system correctly.
What makes a denials program
robust?
Robustness comes from making sure
that you have the expertise, technology
and the right type of staff. Once upon a
time, all we needed was billers, but now
we have attorneys, coders and nurses.
We are trying to make sure the coding
and medical necessity are correct. If
everything is there clinically but the
claim still gets denied, then it is time to
get attorneys involved.
What solutions do even some of the
top healthcare organizations not
try? Why not?
Many of them do not use the legal
options. They have denial departments
and people filing appeals, but they are
not open to using the legal system.
Many insurance payers know they owe
us, but they delay payments again and
again. Engaging attorneys, sending
demand letters and going into arbitra-
tion resulted in more claims getting
paid. Unfortunately, sometimes we
reach the point where we have done all
that we can clinically, so we have to use
other tactics. Hospitals are now
becoming more open to that. We are
trying to get paid for services provided.
What we have found is that all it takes
is a demand letter from the attorney to
start the conversation.
What other pressures are
healthcare CFOs under today? What
would ease those?
We are all trying to figure out how we
can recover two years of lost revenue. I
am not sure if we can. Staffing is a huge
issue, we are all a part of the “Great
Resignation”. We need to find a way to
diversify revenue but there are fewer
avenues than before. Some hospitals
have stopped offering services that do
not bring in enough reimbursement to
cover cost. Larger systems are
consolidating services. We know
telemedicine, and healthcare at home,
is the future, and it will keep growing.
We are in the age of disruption, and
need to embrace the fact that people do
not want to come into the building
anymore. We do not have all the
answers yet. There is a reason why
telehealth did not grow rapidly before
the pandemic. Payers didn’t want to pay
for it. We need to think about
healthcare differently, to find other
ways to reach patients and provide
care. The health systems that come up
with ways to do that cost effectively,
and be reimbursed for it appropriately,
will have a competitive advantage.
Any final words of advice?
The last two years should have taught
us that we have to become real partners
with our payers. We say we are
partners, but we continue to make it
harder and harder for patients to
receive care.
For us to do what is right for the
patient, hospitals and payers will need
to work together to streamline the
system, remove administrative burden
of processes, such as pre-certifications,
and denials.
We are now trying
to determine what
may cause a
denial before the
claim is submitted
How Healthcare CFOs Can Better
Manage and Prevent Denials

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