Effective clinical denials management requires multi-stakeholder buy-in and role appreciation.
What are some tips for working with clinical denials?
Noel Juaire: “The key piece here is to understand which items truly are driven by the clinician (and thus more controllable) and which are maybe a little bit more in the gray area.
“And at the end of the day, it's really about prevention than trying to do response. We can look at medical necessity denials and have clinicians help write responses, and that gives us some better patterns for us to potentially be able to tackle some of those without them. But (those efforts aside), you're still having a denial. So it's going to take getting to the root cause to figure out what is causing that denial and how you can prevent it. In many instances, those delivering care don't know about a medical policy (affecting payment from the insurer). And quite honestly, there's so much variation from payer to payer on what services may be covered or not, that it really is not fair to even ask the clinicians to try to know that. So really the question is, ‘Can you build systems around conforming to policies?’
”Or if you have a team that's working on identifying pre-authorization needs associated with a particular service that's being scheduled, can you detect whether it's likely to have a potential challenge and let the clinician know, so that the clinician can determine whether the service absolutely has to be done and recognizes there could be risk of getting paid or whether there's some other option of equal clinical effectiveness without risking payment. So I think that's the most important aspect. You need to start to engage theas in identifying the impact of the denial.
“And then also to, from the back end, really explain how much that clinical denial could financially impact the organization. In some cases, it may not be a huge amount of dollars from a revenue impact. But you have to think about the fact that we're also incurring that cost.
“Cost is actually something that every organization is highly focused on. We really want to be providing the most value where we can. So if there is something we really have to do, then that involves being very judicious and really scrutinizing what services we may want to take the medical necessity denial on and accept the fact that we have to do that because it's our standard of care.”
