§ Missy Harbert & Linda Mescher § Bottom Line Systems | Revecore § HFMA 2019 Biennial Tri-State Fall Institute § 9.13.19
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§ Defining and standardizing “root cause” § Identifying denial trends through root cause analysis and reports § Cutting down the tallest trees § Identifying key stakeholders to own, develop and implement best practices to improve identified areas/issues § Short & long term monitoring through evidence based KPI’s § Identify strategies for overturning/resolving denials § Defining key components of a Denials Team § Identify key strategies for denial prevention § Explore difficult denial situations 3
Average claim denial rate for large hospitals, by region § Average claim denial rates for large hospitals, organized by geographic region, according to the Revenue Cycle Index. § Northern Plains — 10.58 percent § South Central — 8.88 percent § Midwest — 7.89 percent § Southern Plains — 7.72 percent § Pacific — 7.58 percent § Northeast — 7.21 percent § Mountain — 7.18 percent § Southeast — 7.14 percent Ayla Ellison - https://www.beckershospitalreview.com/finance/average-claim-denial-rate-for-large-hospitals-by-region.html 4
§ According to the Advisory Board: § About 2/3 of denials are recoverable, and 90% are preventable (2014 study) § Denials cost health care networks approx 3% of their net revenue stream § Can be difference between a – and + balance sheet § No longer a “tolerable” cost of doing business “An ounce of prevention pays off: 90% of denials are preventable.” The Advisory Board Company, Dec. 11, 2014 5
§ Critical to develop and define each root cause category, with relatable examples. § 1 st level – broad, typically assigned based on CARC/remark code § 2 nd level – detailed, typically assigned based on review of all available information internally and from payer § Scalable, repeatable training of any associates who will be applying the root cause to a denial. § Ensure there is as little cross-over between root cause categories as possible § Standardization allows for most accurate comparisons between facilities and date spans 6
§ All reporting should reflect both dollars and volume of accounts § The claim level data that makes up the reports must be “one click” accessible § Repeatable high-level views that can be reviewed at established intervals (weekly, monthly, etc…) § Ad-Hoc capability for “deep dive” § Distribute and review with all key stakeholders 7
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FY17 D/C Authorization Root Cause Details June July August September October November December FY17 Total FY17 Avg Detailed Root Cause A $ 11,146 $ 62,784 $ - $ - $ - $ 608 $ - $81,186 $6,766 Detailed Root Cause B $ - $ - $ - $ - $ 49,770 $ - $ - $49,770 $4,148 Detailed Root Cause C $ - $ - $ 12,646 $ 4,985 $ - $ - $ - $176,256 $14,688 Detailed Root Cause D $ - $ - $ 1,063 $ 14,086 $ - $ - $ 1,820 $16,970 $1,414 Detailed Root Cause E $ - $ - $ - $ - $ 45,830 $ 3,293 $ 12,468 $109,915 $9,160 Detailed Root Cause F $ 629,565 $ 751,702 $ 909,205 $ 916,109 $ 690,596 $ 1,131,168 $ 392,944 $6,953,016 $579,418 Detailed Root Cause G $ 9,412 $ - $ 30,291 $ 647 $ 27,068 $ 5,181 $ 1,004 $78,635 $6,553 Detailed Root Cause H $ 7,174 $ 27,616 $ 70,731 $ 92,842 $ 11,345 $ 47 $ 12,605 $248,636 $20,720 Detailed Root Cause I $ 3,716 $ - $ 12,304 $ 20,543 $ 39,384 $ 8,108 $ 8,808 $120,724 $10,060 Detailed Root Cause J $ - $ - $ - $ - $ - $ 5,052 $ - $5,052 $421 Detailed Root Cause K $ - $ 12,426 $ - $ - $ - $ - $ - $12,426 $1,036 Detailed Root Cause L $ - $ 638 $ - $ - $ - $ 83 $ - $721 $60 Detailed Root Cause M $ 565 $ - $ - $ - $ 575 $ 641 $ - $1,781 $148 Detailed Root Cause N $ - $ - $ - $ - $ - $ - $ - $3,313 $276 Detailed Root Cause O $ 6,591 $ - $ - $ - $ - $ - $ - $6,591 $549 Detailed Root Cause P $ - $ - $ - $ 416 $ - $ - $ 918 $16,770 $1,397 Detailed Root Cause Q $ 62,564 $ 31,720 $ 60,601 $ 68,297 $ 24,433 $ 64,871 $ 119,061 $553,391 $46,116 Detailed Root Cause R $ - $ - $ 8,169 $ - $ - $ 96 $ 96 $8,361 $697 Detailed Root Cause S $ 22,312 $ 7,780 $ 48,885 $ 12,916 $ 44,324 $ 34,015 $ 32,715 $211,536 $17,628 Grand Total $721,254 $753,046 $894,665 $1,153,897 $1,130,841 $933,326 $1,253,162 $582,438 $8,655,048 9
§ Can be, but does not HAVE to be, the largest volume or dollars § “Domino Affect” § Cause and Effect Matrix § Consider complexity of issue, number of processes affected, size of department/area for scalability and available resource for best practice/end stage implementation 10
§ Mix of experience and outside eyes, thinkers, and doers § Authority to make and implement changes § Ability to test hypotheses and document results § Set objectives and goals with deadlines and check-ins § Communicate and begin implementation of best-practice to improve or fix identified area § Set up standing meetings to review and summarize success of initiative/needed follow up 11
§ Business Intelligence, Analytics, Dashboards § Establish measurable benchmarks and goals § Review at intervals, starting frequently (daily/weekly) and then if successful moving to monthly/quarterly § Audit to ensure “false positives” do not exist § Engage other areas as needed § i.e. managed care § Pivot/change as you gain more (potentially better) data 12
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Where to Focus- Denial Resolution or Prevention? It is critical to have both
§ Strong Denial/Appeal Team is needed- § Either insourced or outsourced § Strong clinical representation with experience in: § Revenue Cycle § Interqual, MCG, NCDs, LCDs, payer medical policies § Knowing when to use which criteria or policy
§ A Strong Denial/Appeal Team , continued § Analysts and clerical staff that can support clinical staff § Allows nurses to be focus on clinical analysis and clinical appeal § Legal input on denial team when needed § Contract issues § Statute involvement § Assist with letter format and wording for increased effectiveness and persuasion § Staff skilled at conducting root cause analysis of the denial
Know your contract t c a t r n o C § Denials for no auth § Does contract allow for review based on medical necessity? § What are your appeal time limits? § Have input and support from Managed Care Team Know your state statutes § Fully vs self funded plan? § Does statute allow a longer appeal limit?
Ø 76 year old male with Anthem Medicare being seen by Pain Management office for increasing radicular back pain despite conservative management Ø Determined to be candidate for epidural steroid injection Ø Procedure ordered and scheduled Ø Authorization required but not done Hospital Claim Ø Claim submitted for CPT 62311 denies upon billing →
• Incorrect LCD cited in denying procedure Anonymous Provider in SW Ohio • WPSIC does not have jurisdiction over this part of the state Wisconsin Physicians Service Insurance Co
Ø 49 year old male with Federal BC/BS seen by sleep medicine due to complaints of excessive daytime sleepiness affecting daily activities, reports of severe snoring, and parasomnia Ø Polysomnography ordered and scheduled Ø Procedure did not require precertification Hospital Claim Ø Claim submitted for CPT 95811 denies upon billing →
§ Guideline for a different study used to deny
Denials are often inappropriately upheld after following payer’s appeal process
Payer Escalation § Must be able and willing to escalate improperly upheld denials § Having the right knowledge on the Appeals Team allows proper/strategic escalation § Know your options: § Escalate to the Payer/Provider Representative § Follow arbitration process § External Appeals- know the escalation process in your area § Department of Insurance, Maximus, other § Referral to Internal Legal Team for possible legal action
§ Line item denial companies- denial issued after review of IB n o t i c e e j R § Know the definition of billed charges in the contract Denied: § Modify contracts to protect from these denials § If this is not possible, review charge master and reallocate charges to room and board where possible/reasonable § Follow appeal process § Fight from a legal perspective
Prevention § Denial Prevention Committee § Multidisciplinary team § PFS, Contract Management, Case Management, Appeals team, Registration, HIM, etc. § Regularly scheduled meetings to § Review denial trends § Develop process improvement initiatives § Monitor the effectiveness of initiatives § Review case studies 25
Is denial related to: root cause § Registration or Access § Authorization § Lack of documentation § Errors in billing or coding § Payer actions and behavior § Utilization/case management 26
§ Precertification Team § Team whose goal is to ensure accurate auth of all planned testing, procedures/surgeries, etc. § If auth not required, consider pre-determination to ensure medical necessity met
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