SSI claims reporting and management series part 3 of 3: Q&A with SSI Revenue Cycle experts regarding key strategies to help you and your organization make improvements in denials management

Now that you’ve read about the top five types of claims denials and the top two KPIs to keep a watchful eye on, SSI experts Lori Brocato and Kaylee House share key strategies to help you and your organization make improvements in denials management.

Q – What are some key strategies for quick wins in terms of improving CCR and IDR?

A – [Kaylee House] I’d be remiss if I didn’t spend some time here talking about edits. First, it’s important to keep an eye on your edit trends and look for changes month over month to determine what affect your edits are having on both your CCR and IDR. Second, it’s a good idea to look for edits that are no longer applicable and turn them off. Third, if you have any “catch all” edits in place, take a look at those and see if it’s possible to break them down further and make them more specific. These first three steps alone should equal a more efficient use of edits on the front end, which typically helps improve claims management down the line.

Fourth, look for bypassed edits and understand what the reasons are for these to determine if you can make any significant and/or subtle changes to these edits that might have a big impact downstream. Lastly, even if you work for an organization that doesn’t have a lot of resources to put toward monitoring and managing your edits, you may find that even setting aside a small amount of time weekly or monthly to review these and make a few tweaks here and there, those small changes could equal big results.

Q – Are there any additional quick win strategies that come to mind when it comes to specific types of denials?

A – [Kaylee House] Yes. The first one that comes to mind has to do with timely filing denials or what is sometimes called never denials. This may not be the most common type of denial, but we often find ignoring these types of denials still equals money being left on the table. And for those that are recoverable, it could be a simple easy fix. I suggest starting with those payers that are the main drivers behind these types of denials and then, focus on those that represent the highest dollar amounts (this holds true for all types of denials). Take a look at specific claims, codes, date and more to try and uncover the how, what, and if you can make changes that would help you avoid these types of denials. I also recommend you schedule weekly reports utilizing your billing and/or reporting system that will help you identify claims that are nearing the timely filing deadline and be sure to include the payer as a filtering field.

The second type of denial that comes to mind is eligibility related denials and these types of denials do happen to fall within the top five most common denials. I believe there are more strategies that could be applied to address issues upstream to reduce these types of denials on the back end. For example, take full advantage of your billing vendor’s edits and at the time of billing, be sure to re-verify eligibility to make sure the coverage is still active or you have the correct payer, etc. As we all know, eligibility information can change from the time you first collected it. This extra step alone can save significant time and money on the back end.

Basically, any denial you can correct and resubmit quickly, those are quick wins in my book.

Q – What advice would you give to those who are looking for help to prioritize working their denials?

A – [Lori Brocato] Well, as Kaylee said, the low hanging fruit are those denials that you can correct and resubmit quickly. So, that’s a good starting point. From there, I’d take a look at prioritizing repetitive denials that might have a simple fix. Is there something these denials have in common that you could fix by implementing a change in your host electronic health record system or that might be able to be automatically plugged in during the download of claims into your billing vendor’s system? These are things that could fix a lot of errored claims or a lot of claims that are being denied for the same reason. I also recommend using your system’s flags, edits, reminders, etc. to address issues, especially those around timely filing. Most systems do provide these types of notifications that can let you know when you’re reaching a timely filing limit and I highly recommend people take advantage of those notices.

Another option is to workflow your denials. There’s technology out there, including what we offer here at the SSI Group, that allows you to automatically assign denials to a resource that is best able to address them. This allows organizations to assign denials to root cause owners based upon where the denial is coming from and it makes sure the best person in that specific area of expertise is the one who addresses it. This also helps educate resources when they’re able to see what errors are occurring so that they can be empowered to implement strategies to help prevent those specific errors from recurring. Technology also allows you to prioritize high dollar denials above lower dollar ones, especially high dollar denials that may have simple quick fixes. You can even use different workflows to specifically address appeals and even prioritize them based on the level of complexity and determine who is best to handle each type.

Ultimately, everyone works denials a little bit differently and it’s important to find what works best for you and your organization. Some organizations use the same staff to handle billing and denials. Others separate out these functions with those focused on follow-up only (rejections, denials, even appeals). And some send denials back to the department or area responsible for the denial. And in some cases, organizations completely outsource their denials.

Q – Are there any specific strategies you recommend around reprocessing claims and filing appeals?

A – [Lori Brocato] I think it’s really important to use electronic submission for reprocessing claims and in some cases, even filing appeals, which gets the claims there faster. And you want to be sure to follow payer specific guidelines for claims resubmission. For example, some payers require you to submit a corrected claim with the XX6/XX7 bill type and others don’t care, meaning you can just correct the original claim and rebill it. Knowing these guidelines is really important, because if you don’t follow them you will just end up with another subsequent denial.

A lot more payers have started offering the ability to file appeals online or they’re at least allowing you to start the process with online forms. In addition, Medicare recently rolled out their Electronic Medical Documentation Requests (eMDR) process where they are electronically sending out requests for medical documentation for their Recovery Audit Contractor (RAC) audits and other types of audits. So they are really getting closer to having a fully electronic process and I’m seeing a lot of other payers moving in this direction as well.

Q – Do you have any tips for tracking and monitoring new denials?

A – [Lori Brocato] Having a monitoring or tracking system in place that helps catch new denials is important. You don’t want them to become commonplace so, catching them quickly is key. In the absence of a technology vendor, you will want to be sure you are able to keeping up with new payer requirements, reading your provider bulletins that you get from your payers, checking payer websites, etc., but hopefully you’re working with a technology partner who does all of this for you. However, even if you are working with a technology partner and a new denial does show up, the first thing I would ask myself is, “Is this a new payer requirement and is this something I need to get an edit put in place for?” or “Did my organization just sign a new contract with a payer and is it possible there’s something new in the contract that we should be accounting for?”.

Q – How do risk based agreements affect denials management and appeals?

A – [Lori Brocato] When it comes to managing claims and denials associated with risk based agreements, it’s especially important to work closely with your clinical team to make sure claims are being coded more accurately, because you can have monies tied up in these claims for treating sicklier patients. Organizations want to make sure they are continuously documenting on those patients for the conditions they are being treated for.

In some cases, it just won’t be worth appealing the claim. For example, maybe you don’t have the documentation to support a service or if the documentation is vague, it might not be worth it to appeal it. Of course, take the dollar amount of the claim into consideration as well as your relationship with that payer, and also maybe even going back to the payer and let them know that you are really working on educating your physician and clinician teams to make sure they are documenting more appropriately and meeting documentation guidelines in the future.

Q – Do you have any final thoughts around denial prevention?

A – [Kaylee House] I’ve read that around ninety percent of denials are preventable. So, if that’s the case, I’d say every organization can make improvements. Here are some additional examples to consider. One, are there edits firing on claims that are still resulting in a denial for the same reason? Is it possible that those edits are being bypassed? Duplicate claim/payment denial reason is one example and then, you have to ask yourself, is there an opportunity for those to be prevented by a change in process on the front end. You just want to always be working smarter, not harder. So, this is an example of something that could be addressed on the front end, but not also on the back end.

In addition, it’s important to remember that you can’t manage what you aren’t measuring. This is true for KPIs, edits, denials, and rejections. All of these are key factors in your revenue cycle performance and need to be measured and monitored. Obviously, software tools will help you significantly in this area and will allow you to keep digging deeper and deeper until you find those root causes.

And ultimately, there will always be things that will be out of your control, but I encourage organizations to get creative in putting forth the effort to put together process improvement strategies that will have the greatest impact.