Becker’s “Ask a Revenue Cycle Leader” series features insights from health system and hospital revenue cycle executives across the country.
Each installment poses a question on a pressing healthcare finance issue, from payer relations and automation to workforce and patient experience. All revenue cycle, finance and reimbursement leaders are invited to respond.
Question: What is one creative solution your team found to a payer problem?
Editor’s note: Responses have been lightly edited for clarity and length.
Angel Hovanessian. Vice President of Revenue Cycle, HIM, CDM and CDI at Emanate Health (Covina, Calif.): One creative solution our team implemented was developing escalation logs to track recurring payer issues, including authorization delays and reimbursement challenges. These logs were shared with health plans, allowing them to follow up internally and provide monthly updates and resolution outcomes. We also partnered with our contracting department to share documented payer challenges and trends, giving them valuable insight to address these concerns during contract renewals. This approach improved accountability, strengthened communication and helped streamline issue resolution, ultimately reducing delays and supporting better continuity of care for our patients.
Tami McMasters Gomez. Executive Director of Mid-Revenue Cycle at UC Davis Health (Sacramento, Calif.): We stopped treating the denial as the problem and started looking upstream for the cause. By identifying payer-specific patterns and building targeted prebill interventions, we are able to prevent issues before the claim drops, reduce unnecessary rework and shift our team from reactive denial management to true denial prevention.
Kaci Ramsey, MSN, RN. Vice President of Revenue Cycle at Confluence Health (Wenatchee, Wash.): One of our most creative approaches has been to stop treating payer problems as solely a back-end revenue cycle issue. When we identify a recurring denial or reimbursement problem, we bring together the teams that influence the entire claim, including operations, authorization, coding and revenue cycle, and work backward to determine where we can intervene before the service or claim occurs. That approach has helped us redesign workflows around payer-specific requirements, reduce preventable reimbursement risk and create greater accountability across departments. Instead of simply getting better at working denials, we are getting better at preventing them.
Wade Wright. Vice President of Revenue Cycle Services at Memorial Health System (Gulfport, Miss.): Predictive denial analytics to strengthen prebill claim edits can significantly reduce what the revenue cycle back end has to address. Payers tell you what problems to avoid in their remittance data, so use that to prevent them from the start. A clinic claim with lab charges with the diagnosis code “obesity complicating pregnancy, second trimester” (O99.212) in the first slot and the diagnosis code “13 weeks gestation of pregnancy” (Z3A.13) in the last slot will pass a regular claim edit but will certainly result in a generic CARC code 16 denial once submitted. Sure, you add a little bit more to DNFB, but improving first-pass yield and avoiding the review and rebill effort after a claim denial is worth it in the long run.
Next question: What is one thing you do to retain your top performers?
If you are interested in responding, please send responses to Andrew Cass at acass@beckershealthcare.com.
