This webinar's purpose was to help healthcare organizations and providers better navigate through denials and payer audits. Specifically, the 4 main goals during the webinar were...
Best practices for improving claim quality and reducing denial.
Opportunities to data mine and know what payers and CMS are looking at.
Provide some new insights into where and how to allocate resources along with some tools to help you get there.
Looked at current denial trends by payer/denial code and a format to measure overturn success with anticipated target goals.
This webinar was very insightful, the two speakers combined for a total of 33 years of experience in the revenue cycle and HIM service industries. We were very pleased to have Charlie from MRA as a special guest!
Q: Can you recommend any resources to aid in overturning some of the denials?
A: We can provide two types of recommendations to aid in the overturning of denials...
- For an internal resource, Etactics has the ability to track denials that have been overturned within your own organization and then a process library to document the necessary steps taken so that those with access to the central repository can look up and read the steps needed to appeal or overturn various denials. Two other good resources would be some databases available from an organization called AAPC (American Academy of Professional Coders). They have information detailed by specialty on how to appeal and overturn various denial codes. This database can also be loaded into the Etactics repository. The other internal resource is from a company called Appeal Solutions Inc. where a variety of different letters and strategies are available as part of their subscription service.
- For external resources, Etactics can recommend a number of RCM partners who provide an outsourced service to handle the overturning of certain denials. Depending on the types of denial and the amount, Etactics can make some recommendations for you.
Q: As a manager how you control the denial claims & How to monitor the ratio?
A: From a management perspective you need to have certain tools that filter, assign, track and monitor denial, appeal and overturn results. Etactics has a robust workflow tool called AppealsPlus and a Denial Analytics Report that accomplishes all of that. You can also search to see what capabilities are already included in your current PM/EHR system or Clearinghouse. You also need a tool that identifies the types of denials that are preventable and then those can be easily overturned and put your attention and resources to those denial types.
Q: Do you have any info on better training for the front desk?
A: A very good resource can be found at an organization called NAHAM. They have a variety of online tutorials and ebooks that discuss various ways to improve and measure the effectiveness of your front desk and Patient Access departments. Another method would be to employ the use of a tool previously mentioned from Etactics called Revenue Vitals that identifies where the actual upfront denials are occurring and then a training program or regular update sessions can be tailored to those specific issues.
Q: How do you limit the amount of payer rejects once the claim passes the clearinghouse?
A: The most effective strategy to limit the amount of payer rejections is to identify them at the clearinghouse level prior to them getting to the payer. We refer to this as a "custom edit" strategy where various rejections are identified through testing or on a regular audit basis of your payer rejections. Edits are then put in place to correct and fix those claims rejected at the clearinghouse prior to submission to the payer. Effective Clearinghouses, such as Etactics, will average an acceptance rate at the payer of 99%. Some of those claims may still be denied after adjudication acceptance, but at least they were able to make it to that stage. These custom payer edits are in addition to the standard CCI, LCD and NCD edits. Some PM/EHR systems also have edit capabilities on the front end. It's a good practice to review your custom edits at least on an annual basis as many change and are no longer needed.