Amid intensifying healthcare industry operational pressures, Tom Buckley, senior vice president of revenue cycle and managed care at Marlton, N.J.-based Virtua Health, has found payer denials to be among the most significant challenges facing the revenue cycle.
“We use the phrase here at Virtua — ‘payer shenanigans’ — is how we like to describe that,” Mr. Buckley said during a Becker’s CFO+Revenue Cycle Podcast episode.
Mr. Buckley has been with Virtua for 37 years. The academic health system comprises five hospitals, two satellite emergency departments, more than 40 ambulatory surgery centers and more than 400 additional care sites, according to its website.
He said diagnosis-related group disagreements and routine downgrades of physician evaluation and management codes have been key pain points. He also emphasized the lack of clarity for the appeal process from the payer perspective.
“For inpatient cases, you are assigned a DRG by our health information management team,” he said. “A lot of our contracts are paid off of those DRGs. The payer will come back and disagree with the DRG assignment, and we’ll have to go through a lengthy exercise to defend our DRG assignment.”
He added that these reviews can require assembling full medical record packets, clinician documentation and coding validation before the payer will even reconsider the claim.
Virtua is also pushing back against denials on the professional side, particularly around its physician group, VMG.
“The payers will come back for E&M coding … and downgrade the E&M code, which, in essence, is paying you less,” Mr. Buckley said.
The appeal process can be made harder due to lack of clarity, starting with how the communication is received. Payer letters can also land throughout the organization, he said. To respond more effectively, Virtua has centralized all denial communications within patient accounting and tightened contract language to limit excessive vendor-driven appeals.
As industry pressures mount, Mr. Buckley said team engagement requires ongoing communication and transparency.
“We have monthly staff meetings where we’ll go through our collective goals and objectives,” he said. “We’ll talk about our cash collections, our days and accounts receivable on the patient access side, [and] we’ll tie patient satisfaction goals back to the registration team to have them understand how important the customer service side is.”
He also said rising patient financial responsibility adds another layer of complexity to revenue cycle operations.
“We offer different programs, [like] financial assistance,” he said. “In essence, what we’re trying to do is make it as easy for the patients as possible to pay their out of pockets. We also have incorporated tools in our Virtua.org website, where individuals can go and figure out what their out-of-pocket is.”
Mr. Buckley said Virtua has increasingly turned to technology and AI, adding tools to help calculate whether patients meet inpatient criteria based on readily available information provided to the system.
