The past few years of denials surges should teach hospital leaders the importance of examining their claims inventory a little differently, according to Robert Boos, VP of Revenue Cycle at Centra Health.
What influence should denials trends over the past few years have on your organization's strategy?
Robert Boos: "In 2020, we stepped into this dangerous and uncertain time––something we've never seen before with the beginnings of a worldwide pandemic. In preparation for this (sudden influx of patients about to affect revenue cycle ops), we had a great number of high-level discussions with payers, partners, advocates, and state associations. We all got together and said, 'We're about to face something none of us have ever seen before. We don't know how bad it's going to be or how long it is going to last. What are we going to do to ensure the continuity of great care to our patients without all the administrative burdens?' And so we had that discussion. We had that giant campfire where we all stood around and sang songs and held hands and chanted Kumbaya, and we were going to do the right thing. And it worked––for about two months.
"And then the payers started to go back to some of their old ways. What we saw operationally was that they started to pull back from the 'no authorization' agreements and from limits on denials. And then they doubled down. They came back and said, 'Well, we are going to start denying claims again and delaying authorizations, asking a provider to submit a medical record or resubmit a claim or COB form. And then we're going to re-ingest (this administrative work) into the payer system. And then we need someone on our side to review it. But guess what? It's the pandemic. We're short-staffed, and there is nobody to do that. So thank you for resubmitting your claim and giving us the attachment that we needed in order to process your claim. But now we're going to take four months or longer to process it.' So now they have doubled down on having an advantage at a time when the rest of us are trying to do the right thing.
"Fast forward to January of 2021, when the Omicron variant hits, and everything really went crazy. Our hospitals were full and trying to move patients on to different levels of care and get other patients in, the ERs were overrun, our patients were in the hallways, and we were running through protective gear. And our partnership with the payers was non-existent. They walked away and said, 'Business as usual for us. Good luck, and we're rooting for you. ' And that's kind of where they left us. So that set the table for today: a feeding ground for payer audits, recoupments, denials, and delays.
"What we learned pretty quickly (in this tough payment climate) is that you've got to go back at them. You have to stand up for every dollar that your health system is producing. Because if you don't, they will see that as a weakness. They will notice you as the one that does not fight back. Think of it like a lion looking at a bunch of antelope running. Do they pursue the fastest-running antelope, or even the antelope in the middle of the herd? No. What does a lion do? They look at the back of the herd for the slower-moving ones that they can catch. And I think that's what happens here. So if you become known as a health system that does not push back, does not respectfully go back and say, 'You've underpaid us...or you've delayed beyond what's reasonable,' then you become more vulnerable.
"And this advice carries down to the lowest balance levels. There has often been a fascination with saying, 'Well, if it's a claim under $500 or under $400, then it's not worth appealing. The cost of the appeal does not equal the effort that we put forward or what we could collect.' And that's true when you do that basic math. But there are such waves of impact beyond that single claim's value, where you become a bigger target and where you may aggregate thousands and thousands of those $500 claims. You soon have $500,000 or even a million dollars in reimbursement (in aggregate) that you see you should be pushing back against.
"You have to train your staff to push for everything that is owed. Use some AI and work listings, and find good partners out there in the vendor space that can help you navigate this (inventory) and fight for every dollar that you should get. Get off that easy list, so you're not an easy mark for a payer anymore... So that they're going to look at you and say, 'Oh that health system, they're going to push back hard.' When the payer is not making any money, they're going to go and find someone else. So be strong up front saying, 'You're not going to get away with this with us.' If it's appropriate and we owe you the money back, absolutely. As fast and quickly as we can (we'll walk away). But if we feel per contract that you owe us the money, then we're not giving it back to you. We're going to fight you for every dollar because that's what we need to do to ensure we fund our organization to take care of our patients and our community. And at the end of the day, that is what is most important."
