Denials Management: Making the Change

At Moffitt Cancer Center, a robust denial prevention program resulted in reducing denials from 14% of gross charges to 8% of gross charges billed. The process involves a multidisciplinary team, a data-driven strategy, a preventative approach and a missional, patient-centric perspective that extends across the organization. The process involved creating a multidisciplinary steering committee, then finding the root causes of their denials and creating a path forward. Finally, they made a change and continued down the path to improvement.

 

Implementing Change

In cases where staff training is key to the initiative, it can be challenging to institute behavior change and encourage staff to adopt a denials prevention mindset across the revenue cycle. Many healthcare organizations find it helpful to record conversations staff members are having with payers, physicians and patients. Trace from Vyne Medical is a healthcare-specific solution that can record face-to-face and phone conversations to ensure key processes like eligibility verification are occurring and provide transparency to leadership if they’re not. With Trace, conversations are indexed automatically to the patient’s record for easy reference during staff performance evaluations.

 

How it Works

For Moffitt, documented proof of payer authorization sped up the appeals process and allows staff to appeal 20-25 claims per day versus 8 per day when appealing just on the basis of medical necessity.

 
 
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Payer Strategies

Culturally, it may also benefit your organization to reframe expectations of payers. Manage expectations internally and make sure employees understand that payers operate from a cost containment strategy. By improving payer relationships, it may be possible to eliminate contract requirements that frequently lead to denials. Schedule regular meetings with payers, and be able to provide examples when escalation does occur. Realistically, healthcare organizations will never be able to completely eliminate denials and should still be prepared when they occur. Solutions like Trace can also help hospitals overturn denials by enabling providers to easily capture critical interactions with payers online or over the phone, attach evidence of preauthorization to the patient record and quickly provide documentation if needed later on.

 
 
 

Tracking Progress

Once the team has agreed on their action items, the project manager should create a tracking document to manage initiatives across disciplines. Here’s an example from HFMA Texas.

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Ongoing Monitoring

As with any project, not every solution will be successful which is why ongoing tracking is so critical. If you’re not seeing progress, make sure staff have implemented the new processes and are properly trained on any new technologies. Then evaluate whether additional actions are needed.

 

To help each area better understand its impact on denial performance, proactively share information about department-relevant denials and actions taken to appeal those claims. This is also an opportunity to conduct root cause analysis of recurrent denials and determine prevention strategies at the department level. At each level of the organization, goals and performance measures should be tied to denial performance for improved awareness and accountability. Send quarterly reports to executive and revenue cycle leaders to ensure transparency and insight across the organization.

The Result

As a financial leader, it’s up to you to shift your organization toward a more proactive approach to denials. While denials prevention does require an additional time commitment, it’s become a top priority for healthcare leaders across the country. While denials will never be eliminated, taking measures to prevent just a percentage of them from occurring will have a substantial impact on your organization’s bottom line. 

We’ve seen our denials go from 14% of gross charges to 8% of gross charges.
— Joanna Weiss, VP Revenue Cycle
 

 
 

Want to learn more about creating a denials management program?

 
DenialsMolly Maron