The finish line with a clinical denial is often set too early, explains Rudy Braccili, Director of A/R Operations at Keck Medicine of USC.
What advice do you have when clinical appeals are exhausted?
Rudy Braccili, Jr.: “If I could give my peers in patient accounting and revenue cycle one piece of advice on how to effectively manage denials, it would be to never give up on obtaining payment for those services that your caregivers provided that were medically necessary. So when I say never give up, I primarily mean make sure that you have in your toolbox a legal collection tool.
"When you lose on appeal, all of us are going to go through all the motions that were required to do so in the contracting process, such as filing reconsiderations or appeals. When you still lose, don't give up on that money: Engage a legal collection firm. It's really a great idea for a number of reasons. One is you have nothing to lose. You only have to pay your attorneys if they recover funds on your behalf. All legal collection firms work on a contingency basis, a percentage of what they collect. So you're only going to win. Also, keep in mind these are dollars that you've already lost. There's no other way to get the money other than filing arbitration or legal action. In addition, it's especially a good idea because the payers [whether or not they want to engage in legal action], have to pay their attorneys win or lose. As soon as you engage collection attorneys on behalf of the hospital, the only way that payers can respond is with legal counsel. So they don't like to do that at all.
"And very often, based on my experience at many different provider sites, you will settle on the way to the courthouse. I'll often think of that million-dollar case where you provided medically necessary services and saved somebody's life. Well, no judge is going to find that you are not owed any money based on the technicality, i.e. you didn't get a full authorization or something like that. So it's a great idea to pursue legal action. Payers don't like to engage, and so oftentimes they'll settle in bulk. So if you have a [significant] group of accounts, be it 700 or 1,000 accounts, while you may not have a great case on every one of them, payers are often very willing to settle before getting to the courthouse. And they will pay you 60 cents on the dollar, etc. So at least you'll walk away with something rather than writing it off and giving up on the account in its entirety.”
