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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

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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


Denial management

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


Reason code example

Reason Code Example


Objectives

Objectives

  • Reduce Denials

  • Improve Cash

  • Reduce Net AR Days

  • Get accounts paid timely without interruption


Questions

Questions


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