Denials, like weeds, are unwanted opportunists; if left unmanaged, they can grow vigorously and be a constant, costly battle.
The most effective way to kill weeds is to remove them at the root. In the case of denials that means getting down to the root cause and nipping it at the source. Fortunately, 90 percent of denials can be prevented with proper attention and care.
Here’s a five-step process to weed out your denials and mitigate future issues:
Step One: Collect Data. Accurate and complete data is essential to digging down to the source of your denials. Recognizing why denials are occurring and prompting staff to identify and document the root cause of each denial allows you to understand where breakdowns are taking place and draw insights to mitigate future denial growth. Simply documenting root cause as “Missing Authorization” or “Not Eligible” is not enough. The staff should dig further and document the denial origin, specifying, for example, if it is an add-on issue, emergent admission, insufficient documentation, etc. Start by collecting existing denial key performance indicators (KPIs) and metrics, ensuring integrity and standardization across your data. Follow that with identifying what additional information is needed in order to form a more complete picture of your denials environment.
Step Two: Measure the Impact. Now that you have good data, exploit your denial dashboards and reports to pinpoint problem areas and measure the impact of operational break-downs. Compare denial trends over months, quarters, and years to uncover “aha” factors in your statistics and answer questions such as “Where are my greatest high-dollar denial issues occurring? How well is each staff member doing in converting denials into payment? Can workflow be better segmented to gain higher levels of efficiency and accountability?”
Step Three: Analyze Metrics. Interrogate your data and stratify denials by type (Eligibility, Medical Necessity, Timely Filing, etc.) and then by root cause. For example, if you are having authorization denials, where do you have opportunities to fix them? Is it a department or an individual issue? Is it a single MD or multiple MDs?
Also, analyze your denial recovery rate. If you’re able to successfully appeal your denials, it is a good indicator that many of those denials could have been prevented in the first place. Understanding where and why denials originated will allow your organization to implement strategies upstream in the revenue cycle, thereby preventing avoidable write-offs in the future.
Step Four: Take Action. Creating a system that allows you to shift from just managing denials (pulling at the weed) to actually preventing denials (pulling at the root) is no easy task. Denials establish roots throughout the revenue cycle, therefore communication and shared goals with enterprise-wide leaders will be key to preventing new denials from spreading prolifically. Seek to create an interdisciplinary denial task force that includes stakeholders from both the revenue cycle and clinical space. Leverage your denial metrics to drive the agenda, and even hold uncomfortable discussions to drive organizational change and proactively avert future denials. Furthermore, it is important to establish strong relationships with payers to not only address denial trends and discrepancies, but also to remain vigilant about changes to your contracts.
Step Five: Control Outcomes. Finally, to keep denials at a minimum, remember the mantra: monitor, improve, monitor! Whether it be expanding on denial tools you have today or exploring new denials technology, use data to drive actionable insights, provide organization-wide visibility, and hold every team member accountable. Denial resolution is not a back-end issue, it is an everyone issue. Seek opportunities to collaborate across your organization by providing targeted education, identifying opportunities to streamline processes, increasing back-to-front communication, and putting stops in place to prevent further denial leakage. At the end of the day, it is better to hold a claim for an extra day and get it out the door correctly than to appeal a denial and get payment 60 days later.
Pulling off only the tops of weeds may be faster in the short-term. In the long term, however, it creates far more work than digging a little deeper and pulling out the root.
The same is true for denials. By using tools and processes that gets to the root causes, providers can save themselves a tremendous amount of time and money addressing repetitive denials over time – with the added benefits of getting paid faster, reducing costly follow-up, and mitigating the likelihood of denials sprouting back in the future.
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