Denials can be a silent killer to any healthcare facility when they aren’t evaluated for their purpose.
Most of us evaluate our aging A/R and denials when they come in. We reach out and make appeals and drive collections forward, but many are not taking the next step. Once you’ve received payment it’s time to evaluate why that payment was initially denied.
The CARCs and RARCs give insight into the reasons behind the denial and from that insight you should be looking at trends. The goal you want to get to is preventive denial management. This means you are tracking and trending denials, reviewing the cause, and implementing mitigation processes.
Tracking & Trending
As with any data analysis it’s critical that you are assessing timely and accurate data. Then you can look at your data. First evaluate all of your denials by payer to determine which payers make up the bulk of your denials. Then dive in by payer and review the top three or four denial CARCs. For this activity disregard any that already make sense like deductibles that are the patients’ responsibility. Evaluate the total dollar amount that the remaining claims represent. This is the bucket of money we want to go after to receive faster next time.
Reviewing the Cause
If you see several denials for “coordination of benefits” or “patient cannot be identified as our insured” this should alert you that education for the front desk/intake staff may be needed. If you see several denials for “services were already paid under a capitated arrangement”, this indicates that your staff is still submitting fee-for-service (FFS) claims on patients who have been attributed into a value-based care arrangement.
Implementing Mitigation Processes
Taking the two examples above think on how you would approach those findings.
For the first,
- Consider re-education of your intake staff
- Scheduling regular recurrence of training
- Evaluate the support systems that exist for staff to identify the right insurance information and plans,
- Listen in on calls and workflows. Are there areas where the script can be updated and optimized?
For the second,
- Review your contract and ensure the accuracy of the claims being denied
- Assess your internal policies for tracking, updating, and flagging attributed patients
- Review the billing processes and where they identify attributed/FFS patients prior to submitting claims.
There are a lot of ways that you can implement mitigation processes. Try to look at the issue from all sides. Think of every individual and piece of technology that touches that issue. How can you optimize each component of that process to avoid denials in the future. This doesn’t just increase the velocity of your revenue cycle, it also decreases the costs associated with filing appeals.
If you don’t have easy access to the analytics required to trend your denials, give us a call. We want to see you get paid faster.