DENIAL MANAGEMENT

1. DENIAL MANAGEMENT WV HFMA Spring Revenue Cycle Workshop 2014 Belinda Bennett & Okey Silman II

2. Denial Management • Keys to reducing Denials • Tools to identify Denials • How to reduce Denials • System Related • Staff Related • QA Processes • Denial Committee • Vendor Assistance • Monitoring and Feedback

3. Tools to Identify Denials • Denial Log to track denials from payers • Rebill Logs – why are we rebilling accounts • Vendor review of Denials and issue report • Review of Authorization Denials • i.e. status billed did not mirror authorization in system • RAC Denials • Install a Denial System

4. How to reduce Denials • QA System • Automated real-time system in Registration • Manual QA System • Process to obtain authorizations, vendor or hospital staff • Process to identify when a service is pre-certified but when in Radiology a test is added or changed – communication between departments and staff to update the pre-certification • Process to ensure when a status changes for a patient that you notify payers for new authorizations for observations, in-patient, etc. • Flash meeting daily to review authorizations, payer requirements, etc. • Charge Master – possible review • Billing System edits • Computer System • Identify settings that may not be correct, i.e. Revenue Code, CPT/HCPCS codes

5. How to reduce Denials • Billing System Edits • Review Payer Contracts Link to a check list for avoiding denials in Payer contracts: http://www.hfma.org/WorkArea/DownloadAsset.aspx?id=19451 • Computer System • Identify settings that may not be correct, i.e. Revenue Code, CPT/HCPCS code, etc.

7. Monitoring and Feedback • Denial Committee reviews • Denial logs and reports • Tracking progress • Provide Feedback to all staff – scheduling, registration, coding, and billing • Provide Feedback to Physicians • i.e. Sterilization Forms required for payers • Authorization issues

8. Denials are commonly classified as clinical, technical/administrative or underpayments, as the following table from the hfm TOOLBOX illustrates:

9. Reason Codes • 835 posting files – need to watch how the reason codes are being posted. • Each payer is different and may utilize a code differently • Each system is different and may post a reason code differently • Claim Adjustment Reason Codes

10. Reason Code Example

11. Objectives • Reduce Denials • Improve Cash • Reduce Net AR Days • Get accounts paid timely without interruption

12. Questions