Where should you look to get ahead of denials? Shannon King, HFMA AZ Board Member, says to keep an eye on these key sources of vulnerability.
Where should revenue cycle leaders first focus to improve denials management performance?
Shannon King: "A piece of advice that I would share is to really engage your team to understand the payer contract language. Train for contract expertise: What is appropriate when it comes to your initial denials? What is not appropriate, and how can we challenge the payers for those initial denials? We are seeing more and more initial denials that are erroneous today, and a lot of that has to do with the payers sending us these initial denials that may not be appropriate. So if we don't know that contract language with our payers, it's really hard for us to challenge them on these initial denials.
“Also, automate workflows to aid claims prioritization. You want to have some type of automation or bot technology that helps escalate more complex and time-sensitive denials in lieu of having to fish for these denials or wait for that correspondence to come in that's associated with the denial. I think it's really important, again, to know our payer timelines as far as when we should be expecting payment or that EOB that's coming through. Did we get paid? Are we not getting paid?
“Third, foster strong cross-team support. Engaging your managed care team is crucial to the success of your denials management program. Pulling in your frontline leaders from patient access to your financial clearance, financial counseling if that's appropriate, even your care coordination teams to say, ‘Look, we have some opportunities here based on level of care,’ and so on and so forth.
“Another recommendation is to create proactive inpatient processes. You want to get in front of these denials. We do a great job with our ancillary services and our imaging services for scheduled cases or things along those lines. But when it comes to the level of care and medical necessity on the hospital side, we have some opportunities for improvement. One thing I would suggest is to get your continuous improvement teams involved and your clinical denials management team and pull in your on-site hospital care coordination team, your social work team, whatever the case may be, so that we can really streamline the denials upfront, get that upstream by ensuring the patients are in the appropriate level of care in advance of that patient coming into the house, medical necessity has been met, and the payer has been notified. It's not just revenue cycle that owns this anymore. It's got to be a collaborative effort with our referring physicians and our clinical partners.”
