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DENIAL MANAGEMENT. WV HFMA Spring Revenue Cycle Workshop 2014 Belinda Bennett & Okey Silman II. Denial Management. Keys to reducing Denials Tools to identify Denials How to reduce Denials System Related Staff Related QA Processes Denial Committee Vendor Assistance

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denial management

DENIAL MANAGEMENT

WV HFMA Spring Revenue Cycle Workshop 2014

Belinda Bennett & Okey Silman II

denial management1
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
tools to identify denials
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
how to reduce denials
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
how to reduce denials1
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.
monitoring and feedback
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
slide8

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

reason codes
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
objectives
Objectives
  • Reduce Denials
  • Improve Cash
  • Reduce Net AR Days
  • Get accounts paid timely without interruption
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