Effectively managing denials and optimizing revenue cycle processes are critical endeavors for healthcare organizations aiming to maintain financial stability and ensure patient engagement and satisfaction. During a panel discussion at the Revenue Integrity: Maximizing Compliant Reimbursement event hosted online in March 2023, Lashunda Murray, Manager of Revenue Integrity for UT Southwestern Medical Center and Alexander Safavi, Manager of Patient Financial Services at Children’s Hospital of Philadelphia (CHOP), shared their perspectives on the common causes of denials and trend analysis, fostering team collaboration, establishing strong workflows, and mastering denial recovery and appeals.
Identifying Common Causes of Denials & Trend Analysis
A primary concern for all organizations is identifying common causes, trends, and errors, that lead to claim denials, and as the root causes of denials are ever changing, this can be a difficult area. Implementing denial management tools and technologies to gain insight into AR trends, and leveraging the EHR was one solution shared by the panelists, while using new applications and strategies for claims processing was another. Alexander Safavi suggested a focus on the 80/20 rule, where focusing efforts on where they can yield the greatest results is very important.
The panelists also focused efforts on proactively addressing recurring issues through batch corrections, and working with payers directly to identify root causes stemming from payer systems, and improving overall claims processing.
Fostering Team Collaboration across the Organization
Effective denial management requires a collaborative effort across multiple technical and clinical departments, and having strong communication and an ability to benchmark and discuss denials across the organization is essential. Holding regular meetings or huddles to discuss trends, issues and goals in a way that involves both front-end and back-end teams in a non-confrontational way was noted as an important step. Numerous attendees noted the importance of providing feedback and fostering collaboration in a way that was not finger-pointing, but rather working towards a common goal.
Lashunda Murray also shared her focus on taking corrective action with teams, so that the same mistakes, once identified, are corrected, freeing resources and focus to move on to new areas of concern, creating a loop of continuous improvement.
Strong Workflows for Clean Claims & First-Pass Payment
In today’s technology-driven revenue cycle, creating and maintaining strong work queues is essential in ensuring clean claims and efficient payment processing, reducing denials and enhancing revenue cycle efficiency. Teams must implement and utilize workflows that prevent issues and improve claim accuracy, and have established and well documented processes for consistency and clarity. The use of claim scrubbers to achieve clean claim rates above industry standards can also not be underestimated as teams look to push percentages of clean claims and first-pass payments in the right direction.
Denial Recover and Appeal Management
Recovering denials and mastering the appeal process is another essential tool in maximizing revenue for hospitals and health systems, with a majority of denials stemming from technical issues. Addressing these technical denials caused by errors in claim submission is essential and returns the conversation back to identifying and correcting errors. Advocating for accurate payments in-line with contractual obligations, and recovering interest from payments due was also discussed, alongside the additional challenge of payer claw-backs. Handling clinical denials with effective collaboration between billing and clinical teams focused on ensuring comprehensive documentation to support successful appeals.
In the intricate landscape of the hospital revenue cycle, the efforts to minimize denials and streamline operations have a direct impact on patient care, financial stability, and the overall success of healthcare institutions. By consistently applying the strategies discussed in this blog post, organizations can foster collaboration, enhance workflows, and improve denial recovery processes. As healthcare professionals continue to refine their approach, they move closer to achieving their financial goals while maintaining a high standard of patient care.