Impact Insights

Jumping In the Pool of Denial Management

Jill Berger-Fiffy

Summer is quickly approaching and now may be a good time to review your denial management strategy. With staff and managers taking well deserved time off, it is important to optimize your staff and their workflows during this time. Here are some suggestions to get you ”swimming” in the right direction:

Improve your strokeSwimming requires precise movements and muscle memory. Similarly, ensure your team is using best practice workflows. Measure both quality and quantity. Ensuring staff understand and can perform their work in a quality manner will allow you to meet/exceed the metrics of your organization.

Stay in your swim lane-Understanding the guardrails of your payers helps to facilitate a good result. Regardless of your overall strategy for working claims (i.e. by payer, alphabetical, by reason code) staff are most efficient when they understand the root cause of the denial.  Proper training is crucial for “one touch” resolution. Working within these constructs, staff can also filter or sort their claims to prioritize based on age or dollar amount or alphabet. Root cause analysis is an important skill that allows staff to escalate concerns to their supervisors/managers and payers, which can ultimately help prevent future denials.

Push the work “upstream.” An Edit Management Workgroup is important and can ensure edits are processed in the correct order.   For example, coding errors should flow to a coding workqueue for review and correction after other edits are completed. Ensure your rules engine captures CCI edits, bundled codes and NDC errors in order to facilitate correct coding.

Learning to breatheTaking a deep breath and looking at your policies and procedures can provide some clues for operational improvements. Ensure your team has a knowledge of payer requirements and understands the rules down to the CPT level. Electronic submission allows claims to process through the claim scrubber as compared to on-demand printing on paper which does not allow the claim to be scrubbed prior to submission and can increase the lag days to a paid claim thus increasing overall A/R.

Avoid Sunburn– Preventing sunburn requires consistent applications of sunscreen throughout the day. Continuous follow up is equally important in denial management. Chris Wyatt, in the July 2015 HFMA article, states that only 34% of rejections are re-worked and re-submitted. Monitor the overall volume and dollars and review these in your monthly payer and staff meetings.

Make the turn – Consider when you need to change direction. If you suspect there is a compliance risk with your time of service collections, review your options.  Some groups have opted to eliminate cash collections to reduce the financial risk.  As a safeguard, avoid potential fraud and ensure you have a separation of duties.

Test the waters-Review your write off policy annually and be sure the “thresholds” make sense. Assess the sign off guidelines in place and the number of sign off’s required for each level.

Do it with passion or not at all– If you are going to swim in the pool, do it with zest! Ensure your team is working efficiently to avoid seeing spikes in you’re A/R while keeping your cash flowing.

So, happy summer, Keep calm and swim on!

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