We’ve all experienced both love and hate for something, admit it. I confess, I continue to experience a love-hate relationship with Denials. Let me explain.
Part of me hates denials because each one is a potential loss of reimbursement for services provided, meaning additional resources are required to attempt reimbursement. They represent an organizational issue that cannot be ignored. Every denial seems to say YOU'RE A LOSER and no one likes to be a loser.
With that as a motivator, I began digging into the root cause of denials. While doing so, I gradually discovered, I love them. At least I love the opportunity to understand the cause. Denials have dollars attached to them so tracing them back is easy.
Often the first challenge to determining a cause is that most denial reporting has too much data and is overwhelming to look at. We find ourselves asking “What are we supposed to do with all this?” The big picture offering what feels like millions of assumptions is overwhelming. That’s cured when you look for the simple fixes instead of looking from a higher elevation.
There is the other side of me that loves denials because sometimes it takes just a small adjustment to make a difference. You can realize success with small wins that compound over time instead of being required to make large costly organizational shifts. Here’s an example of looking at the details making a difference:
1. Review denials by financial class - both dollars and quantity
- Is there a big variation? Yes?
- Trace it back to the why. Was it a big dollar claim that is skewing the numbers?
What is the unique issues with this claim? Are there others like it? Yes?
Make a change to ensure that this specific big dollar claim does not deny agai
2. Look at your denials by Payer and Denial Reason Code
- Does one payer stand out among others as having more denials for a specific reason?
- What is happening from this payer to cause this issue?
- For example, it is denying for No Authorization on File
- Is there a specific procedure or CPT code that jumps to the top as not having an Authorization?
- What about location? Is there one location that has more than another?
3. Once you ask a few questions look for one specific item to address
- Was there a change to your contract that you need to educate on?
- Is a specific office location not completing the authorization for the procedure?
- Is there a documentation issue preventing the identification of an authorization?
- Is someone in the scheduling office missing a step? Is it always the same person?
- Is the coding or initial billing not matching correctly against the authorization?
Solving for a simpler answer, like in this example, you can easily identify and implement a fix. If this is not your initial approach to denials, I suggest taking one item a month to apply this practice to then solidifying a simple solution. Focusing on a bit of the minutia could end up preventing lost revenue and potentially remedy the initial hatred we all have for denials.
About The Author
OUTPARTNERING™ CENTER FOR HEALTHCARE RESOURCE GROUP, INC.
Client care is top priority for Jason Coffin, a Certified Revenue Cycle Expert (CRCE-1), CHFP. Jason oversees all operations at HRG’s OutPartnering™ Center in Spokane Valley, Washington and is responsible for Central Business Office (CBO), Extended Business Office (EBO), and self-pay services. He is focused on continuous improvement initiatives to ensure HRG remains the best choice for healthcare providers. Jason and his team provide outsourced revenue cycle services and support to hospitals and clinics across the country.