“Like most, we are trying to be more creative in navigating new behaviors from payers playing by their own rules, such as obscure criteria for downgrades, additional tactics to delay payment through requests for information, and trends of decreasing overturn rates, while continuing to focus on reducing cost to collect,” she told Becker’s.
Ms. Carlson said the system’s efforts now focus less on trends and overturn and more on root cause and prevention.
“While some denial analyses can group denials into target pursuits such as a specific medical policy, denial data is not always easy to convert into actionable insights due to various contributing factors and each denial’s tendency to take on a life of its own,” she said. “Our analytics efforts have therefore shifted from informational reporting to root-cause investigation to facilitate a deeper dive into denial data, enabling us to identify clear failure modes and meaningfully engage clinical departments with education and quick-win initiatives.”
WVU Medicine has restructured its denials management team to integrate denial prevention efforts into its inpatient and outpatient clinical revenue cycle teams and has shifted from facility-specific assessments to service-line task forces.
“Most importantly, we bring everyone to the table: clinical departments, IT, physician advisors, finance, payer relations and legal,” she said. “These teams operate in a model that prioritizes high-impact denials, but we continue to explore methods to facilitate quicker resolution through automated workflows and AI-generated appeals. The current environment necessitates a multi-faceted approach that allows you to be agile and test approaches early and often, constantly assessing the effectiveness of your efforts.”
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