8 Ways Organizations Can Resolve Denial Management

Denial management

Top tips from Keith Olenik, our HIM expert and VP, Revenue Cycle Services.

Think more about protocol driven care.

Having tight protocols around how the patient is referred, how the patient is admitted, how the patient is treated and then how the patient is discharged.

Centralize the process.

Denials can come into the organization from many different departments. They can come into the HIM department, the billing department or they can come into case management. Not everybody knows where all the denials are coming from. Providers must understand where the issues are in order to respond to them in a coordinated fashion, put solutions in place and to educate the staff.

Be able to track the denials.

After centralization of the process, how do you document and track denials so that you can trend and make viewable to all parties? Because there is a time period, you only have so long to respond to a denial before your window of opportunity has closed. If you have to go to the appeal process, which goes beyond the denials, tracking it and having it documented is crucial.

Consider clinical documentation.

The industry has improved since ICD-10 and gotten better at coding and documenting, but we still have a way to go in terms of providing comprehensive high-quality clinical documentation. The role of the clinical documentation improvement specialist becomes critical. The use of virtual scribes becomes valuable to make sure we allow doctors to do what they are good at, which is diagnosing and treating patients — while at the same time, we do not lose the value of the documentation for that particular encounter or part of the patient’s history. We are then better at identifying that patient’s condition, treating them and billing appropriately.

Submit the right documentation.

Make sure the people involved in this entire process understand what the denial is and what they need to provide in order to make the denial invalid. If they do not understand that, they need to be educated. Sometimes it requires a multidisciplinary process of clinicians, HIM and patient financial services — people who all have a piece of the process — to know what they are looking for in order to refute the denial. Individual organizations, like not-for-profits, may make a decision to not bill for a particular service, but still need to record the fact that the service has been provided. The ability to comprehensively document the clinical process is still important whether there is a price attached to it or not.

Create organizational strategy.

Design an organization capable of taking on the challenge of remediating denials. It is not just one person. It requires multidisciplinary involvement. However, you do need somebody to head up that particular initiative and set a clear strategy for how to deal with it.

Make data the king.

If you do not have a way to track, monitor and develop the solutions, you are not going to be able to solve every problem. Get the data, prioritize it and implement solutions, because at the end of the day we want to prevent denials from happening, though we know they are going to happen. You need to have a process in place to try to reduce the denials that you can, so you can deal with the payers as they change the rules year after year.

Invest in the staff and resources.

Prioritize the staff you utilize to do this denial management work. They need to function at a much higher level than we typically saw in healthcare organizations previously. The manual jobs go away, but there is work that needs to be done at a higher level. Invest in the people who have the education, the skills and the competency to work at a higher level to help manage the whole reimbursement process as it continues to change and evolve.

Listen to more advice on getting started with denial management in our podcast, “Get to the Point.”