Errors or typos made by registrars during the collection of information or during the data entry process are “extremely prevalent” in claims denials, according to Brinn Leach-Wilson, a Merritt Island, FL-based consultant with BHM Healthcare Solutions.
“This is not a good reason to get a denial,” says Leach-Wilson. To increase the likelihood of problem-free reimbursement, staff training becomes paramount. “Staff members should be well-versed in submitting clean claims, and even more important, in understanding why claims are denied,” says Leach-Wilson.
She says leaders of patient access departments should take the following steps to prevent denials, instead of appealing them after the fact:
1. Build a denial recovery unit.
“A good denial recovery unit has three critical functions,” says Leach-Wilson. These are:
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denial prevention, which includes developing a standardized process to report failed bill and claim issues, with action expected by the accountable department;
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denial coordination, which entails defining the accountability of each department and defining terms such as “rejection,” “revenue loss,” and “underpayment”;
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denial recovery, which includes establishing rejection and revenue loss trends and write-off rules.
2. Create a denial data database to track the following:
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total claims filed to a payer (number and total charge amount);
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number and dollar value of denied line items.
The data then should be used to calculate percentage denied for the entire organization/system and also by payer, reason, provider, specialty, and location.
“In order to count the number of denials by reason, the organization first needs to determine the categories that will be utilized to track all claim denials,” says Leach-Wilson. Then, map the payer reasons to the organization’s specific reason categories, such as registration or medical necessity.
3. Collect information from the denial database to determine root causes.
For example, if the database says 10% of denials are due to registration-related issues across three locations in the organization, that’s not enough information to act on. The next step is to look at each location to get more specific data, says Leach-Wilson.
The database might reveal that the three locations have denial rates of 3%, 16%, and 25%. While the first location needs only refresher training, the other locations need process improvement and remedial training. “Without the location-specific data, organizations could expend considerable resources and time in areas that may not affect the outcome,” says Leach-Wilson.
WORK WITH PAYERS
At Medical Center of Plano (TX), members of the patient access staff used to obtain authorizations on behalf of physicians, but some payers no longer allow this situation.
“They are saying the physician has to get the auth themselves,” says chief financial officer Melissa McLeroy, MBA. “That has made it even more difficult for us.”
Physicians’ offices had to add staff to handle authorizations. “This puts us in the middle, going back and forth between the physician and the payer to find out why authorizations are not yet in place,” says McLeroy.
Patient access leaders educate physician’s offices on payer requirements in person and build relationships in the process. These personal connections can speed the process of getting authorizations in place, which can prevent claims denials.
“Certain schedulers work with certain physician offices on a regular basis,” McLeroy says. “We always try to get a handoff when there’s turnover, which happens on both sides.”
