[PPT] - Missy Harbert & Linda Mescher Bottom Line Systems | Revecore PowerPoint Presentation

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§ 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

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§ 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

Average claim denial rate for large hospitals, by region

Ayla Ellison - https://www.beckershospitalreview.com/finance/average-claim-denial-rate-for-large-hospitals-by-region.html

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§ 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

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§ Critical to develop and define each root cause category, with

relatable examples.

§ 1st level – broad, typically assigned based on CARC/remark code § 2nd 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

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§ 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

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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

$753,046 $894,665 $1,153,897 $1,130,841 $933,326 $1,253,162 $582,438 $8,655,048

$721,254

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§ 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

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§ 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

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§ 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

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Where to Focus- Denial Resolution or Prevention? It is critical to have both

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§ 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

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§ 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

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Know your contract

§ 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

C

n

t r a c t

Know your state statutes

§ Fully vs self funded plan? § Does statute allow a longer appeal limit?

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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 Ø Claim submitted for CPT 62311 denies upon billing → Hospital Claim

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Incorrect LCD

cited in denying procedure

WPSIC does not

have jurisdiction over this part of the state

Wisconsin Physicians Service Insurance Co Anonymous Provider in SW Ohio

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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 Ø Claim submitted for CPT 95811 denies upon billing →

Hospital Claim

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§ Guideline

for a different study used to deny

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Denials are often inappropriately upheld after following payer’s appeal process

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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

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§ Line item denial companies- denial issued

after review of IB

§ Know the definition of billed charges in the

contract

§ 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

R e j e c t i

n

Denied:

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§ 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

Prevention

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Is denial related to:

§ Registration or Access § Authorization § Lack of documentation § Errors in billing or coding § Payer actions and behavior § Utilization/case management

root cause

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§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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§ Registration accuracy-

§ Some studies show 30-40% of denials attributed to

registration errors

§ Accuracy allows plan requirements to be followed

§ Notification time limits, authorization requirements § Reduced denials for § Non-covered § Medical necessity

§ Allows for more accurate billing, fewer denials,

quicker payment

www.healthleadersmedia.com/finance/rethinking-denials-management

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§ Strong Case Management Program

§ Clinicians with Revenue Cycle knowledge § Advanced payer criteria knowledge § Patient status verification

§ Clinical presence in the ED § Real time information related to pt condition § Clinical documentation § Specialized department for correct status verification § Centralized area that services all network facilities § IP only procedures § Surgery scheduling Ca Case Ma Management

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§ Strong Case Management Program, continued

§ Ongoing Case Management review throughout

admission

§ For appropriateness of continued stay § Confirmation that pt meets discharge parameters § Clerical staff to confirm- § that payer received clinicals § confirm approval vs denial, follow up accordingly Ca Case Ma Management

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§ Physician Advisor

§ For disagreements in patient status:

§ The attending physician Case Management § The attending physician/Case Management Payer

§ For peer to peer reviews with payer

§ When attending physician unable/unwilling to have peer to

peer

§ Related to initial status and/or continued stay

§ For ongoing education of medical staff related to pt

status criteria

Denials can

ften be

remedied by a peer to peer review.

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§ Quality Coding Department

§ ICD-10 increased procedure and diagnostic code

seven-fold

§ Claims/Billing

§ Know your payer requirements

§ Are auth numbers required on the claim?

§ Contract Management

§ Revision of contracts to protect against denials

Coding

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Patient Name Root Cause Analysis Detail Notes Payer Notes Case Study #1 IP admission denied at time IP auth requested Denial letter: No denial letter received, verbal denial from payer 7/5/19, eob denial also indicates could be observation Insurance: United Healthcare Vendor Details: Denied full IP admission Appealed on 8/15/19, payer response pending. Anticipate approval, escalate if not. Rep: 7/30/19 Jenny- UHC confirmed IP denied med nec, ref# 25641285 Authorized Days: 0 Denied Days: Full IP admission denied Total Chrgs: $67,696.52 IP Admission: 7/3/19-7/8/19 Day of Admit: Wednesday Full admission 7/3/19-7/8/18 denied for level of care Criteria: UHC uses MCG. Pt met MCG M-326 Renal failure, 3 fold rise in creatinine from baseline, serum creatinine 4.0, acute respiratory failure

UM notes/Epic: Reviews sent 7/5, on 7/8/19 UHC indicated this

could be observation. No further clinicals sent to payer Primary Payer: United Healthcare Observations/Opportunities: 1) Interqual was used on an MCG payer 2) Daily/additional reviews not sent 3) Copy and paste used in review 4) Denial from payer not addressed by UM 5) No documentation related to peer to peer option Plan: Appealed on 8/15/19, payer response pending Forensic Suggestions:

Utilize the same criteria in reviews as the payer uses
Minimize use of copy/paste as this hinder/dilute the argument

for IP. Best practice would be to summarize review with key points based on criteria

Consider weekend Case Management coverage
Consider peer to peer when criteria met but payer denying

EMR: Pt was IP admission via ER for respiratory

failure. Dx with legionella pneumonia, sepsis. Pt

also w/ metabolic acidosis with acute on chronic renal failure placed on IV bicarb. Discharge DX: Sepsis, unspecified organism

Delays/Avoidable Days: n/a

Paid Amount: $0.00 Underpaid: $22,681.65 Post Appeal Paid: pending Timely Filing: 1/16/20 Clinicals Sent: 7/5/19

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§ Large health system with 10 hospitals and multiple freestanding

facilities

§ Identified areas of improvement needed – OP Authorization and

Medical Necessity Denials

§ Root cause denial tracking implemented by encounter location

(ED, SDS, Cancer Center, etc…)

§ Root cause denial tracking implemented by payer and discharge

date

§ Focus groups created to resolve discovered fail points

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§ Commercial Payer had released a policy update limiting

certain drugs to a site of care provision

§ Initial dose was allowed and authorized at hospital based facility,

but subsequent doses were to be done in freestanding ASC or via home infusion (with some exceptions based on patient tolerance)

§ Provider did not have a mechanism to catch subsequent doses,

therefore drugs were being dispensed and denied for site of care

§ Focus group implemented a flag for the affected J-codes, and

alternate arrangements were made for patients who did not qualify to receive the drug in a hospital setting.

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§ Two commercial payers who used independent parties for

authorization reviews were denying claims in error due to a linking issue in their system

§ The IP was authorizing the service, granting an authorization number,

but failing to transmit/communicate the approval to the health insurer

§ Claims were being billed with the approved authorization numbers

from the IP , however then denying for no authorization with the payer

§ Focus group worked with managed care to initiate discussion with

the payer. Payer agreed to retro-review the affected claims and re- adjudicate for payment with interest

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§ Thorough tracking and trending of denials § Root cause analysis is done consistently and used in order to allow

improvements to the front end of revenue cycle

§ Denials Prevention and/or Resolution team with key individuals and skill sets § Addressing denials from an organization-wide approach with heavy

consideration of how financial and clinical factors intersect

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