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With claims denial tools, look before you leap
Is it user-friendly?
Is your patient access department considering investing in software to decrease and manage claims denials? If so, compliance and customer service must be considered, says Katherine H. Murphy, vice president of access solutions at Nebo Systems, a division of Passport Health Communications in Franklin, TN.
Murphy recommends "one-stop shopping" for multiple features such as insurance benefits, quality assurance, estimates, payments plans, charity assessment, and propensity to pay.
"This makes good sense operationally, since they offer streamlining and continuity to the users," says Murphy. "Of course, we cannot dispute that cost, space issues, storage issues, and adaptation to future technologies that will one day be a replacement must be considered. There is so much to choose from these days."
Card readers, biometrics, and self-service kiosks all play into managing and reducing claims denials when strategically introduced and managed, says Murphy.
Answer these questions
"I have found that assessing the level of intensity of education of the users is highly significant," says Murphy.
If an application is not user-friendly, it "simply will not be used as well and as often as you would want," says Murphy. She says to ask these questions:
• Is it easy to get user feedback to promote better use?
• What problem are you solving? Is it an organizational goal, compliance, or a design flaw of some sort that you are trying to solve?
• Can the technology accommodate local and national legislation requirements?
• Will the automation be efficient in the environment in which it will be used?
• Do the physicians, staff, and patients realize a benefit?
• Is it easy to use? Is a lot of training required?
• Am I paying for bells and whistles that I don't need?
• Do the data need to be managed?
• Is the program customizable without costs?
• What is the implementation time?
• What changes can I maintain?
Murphy recommends these approaches after implementing claims denials tools:
• Don't measure too much.
"Reporting capability and flexibility is highly significant. Yet, some things that are measurable do not need to be measured," says Murphy. "So beware of measuring fatigue. Seek the right level."
• Rewrite policies to align with any changes you make.
"This is the perfect time to update your internal policy and procedures," says Murphy. "Revise the existing processes, and then automate them. Don't automate any existing inefficient processes. They will likely be even more inefficient."
• Be visible and accessible to all stakeholders.
"Demonstrate your commitment to moving forward with the technology initiative," says Murphy. "Think about communicating 10 times more than usual."
• Allow a couple of your department "superstars" to participate in the technology selection process.
"They can provide a reality check that is necessary to make a best choice," says Murphy. "And keeping true to what we hold dear in patient access, remain service-driven and be the champion of change."
John Woerly, RHIA, CHAM, a senior manager at Accenture in Indianapolis, IN, says that the most effective way to manage claim denials is through good documentation, accurate procedures, an educated staff, and front-end resolutions.
"Technology plays an important part in both preventing and recovering denials. But it is only one part of the equation," says Woerly. Process redesign, training, and follow-through also are essential components.
Woerly suggests these key processes to effectively manage denials:
• Ensure complete and timely service documentation.
• Improve registration data quality.
• Conduct concurrent utilization review.
• Consolidate pre-certification, authorization, and recertification functions into a single department.
• Share pre-certification requirements with physicians' offices.
• Provide physicians with regular feedback on clinical denials rates.
• Hold regular meetings with payers to discuss denials issues.
• Regularly distribute contract terms to revenue cycle employees.
• Make sure all denials reason codes are actionable.
• Track observation and inpatient authorizations separately.
• Inform revenue cycle employees of contract changes before the effective date.
• Exchange structured feedback between the revenue cycle, utilization review/case management, and managed care departments.
• Schedule non-emergency services 12 hours or more in advance, to help prevent both medical and technical denials.
• Track denials by payer, reason, and financial consequence.
• Distinguish between technical and clinical denials.
• Track denials by physician, DRG, and department.
• Ensure that contractual allowances are increasing more slowly than gross revenue. "This is a check to make sure that A/R is not being written off to reduce days in A/R," says Woerly.
• Have a dedicated denials units with payer-specific appeals experience.
• Respond to clinical documentation requests within 14 days.
Woerly says that tracking performance is the biggest benefit that both revenue cycle and clinical departments stand to gain with the use of claims denials software.
"It is amazing the number of health care facilities that truly have no idea of the number and dollar amount in denials, let alone where those denials are coming from," he says. "Being able to track performance, and then to proactively act upon findings, is essential to denial prevention."
Murphy says that when claims denials software is implemented, "there will be a higher level of accountability and tracking. This may change workflows and move them from one role to another. This requires strong support from the executive level."
For example, financial counseling tasks may be moved to scheduling or pre-registration areas, since patients may need to reschedule if they are without the proper authorizations. "Working smarter and more timely on issues of a critical nature is a bonus of using such software," says Murphy. "There is less paper."
However, without planning carefully, a patient access department may not reap the hoped-for benefits. "I have encountered folks who have the idea that you just plug it in and it works," says Murphy. "The software must be embraced and managed. It must be maintained."
Murphy says, "Finding the best expertise needed to manage the changes within the organization can be an interesting journey. This is the time to see who steps up to the plate to be the champion."
[For more information, contact: Katherine Murphy, Director Access Services, Passport Health Communications Inc., 720 Cool Springs Boulevard, Suite 200, Franklin, TN 37067. Phone: (615) 661-5657. E-mail: email@example.com; John Woerly, RHIA, CHAM, Senior Manager, Accenture, Indianapolis, IN. Phone: (317) 590-3067. E-mail: firstname.lastname@example.org.]