by Sandy Routhier, VP Revenue Integrity, RHIA, CCS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer
University of California at San Diego Executive Director, System Revenue Cycle, Laura Handy-Oldham, and Huron Senior Director, Isaac Sieling, shared an informative and compelling vignette called “Living in a State of Denial”. The play on words sums up the topic well. Here is a summary of the presentation and a few nuggets we pulled together.
Challenge: In 2015, UCSD was facing denials from across the spectrum of the revenue cycle, resulting in a significant financial impact and re-work.
Solution: The success of cleaning up the denials challenge required these important factors driving change:
- Governance: The challenges and goals of the project being sponsored as an executive mandate lead to organizational change and the buy-in of a new department and position in the organization called Continuous Improvement.
- Accountable Communication Channels: The Continuous Improvement director took a highly fragmented program with multiple partial owners across the organization and brought it under one umbrella to build and manage a denials program that improved upstream and downstream efforts in billing, coding, documentation, and follow-up. Implementing tactics like a clinical appeals team with solid appeal letter language in a template format and physician education on cases where improved documentation could improve inpatient admission criteria. and realigning the reporting structure for HIM & Coding from IT to System Revenue Cycle.
- Technology: Adding in a much-needed denials management system that not only created an operational solution to capture denials information accurately and at the correct level while identifying, routing, and reporting on denials, but also providing analytics on denials to more accurately predict trends with the goal of driving efficiencies by performing root cause analysis in an effort to prevent future denials. A robust denial dashboard was created and they have explored the use of machine learning for predictive analytics with the help of their university partners.
Results: Exceeded expectation with 118% of the $1.5 million recovery goal collected with more to come as only 41% of the appeals have been resolved to date. The overturn rate is currently 92% and they have realized a 41% decrease in initial denials over a six month period.
Summary: The session concluded with a lively 30-minute Q&A session that focused on questions related to subjects such as process, technology, staffing, trends, and solutions. It was evident by the audience participation during this session that denial management is a hot topic in the revenue cycle.
Aiming for Accuracy: As inpatient coding and documentation experts, we noticed that one of main buckets for denials was related to HIM and coding. Although it wasn’t expanded on in the presentation, we thought we would add four tips to mitigate the risk of future denials:
- Take a proactive approach: When it comes for DRG and clinical validation, it shouldn’t be a wait-and-see game with our payers! Hospitals should be taking a proactive approach related to the accuracy of their coded data and supporting documentation. This can be accomplished through internal and/or external auditing processes. Have you performed a DRG validation audit since ICD-10 went into effect more than a year ago? It’s surprising how many facilities have not.
- Trend DRG revisions: Inpatient coding professionals should be involved in reviewing and appealing DRG revisions suggested by the payers. Any trends identified should be shared with the coding team members to heighten their awareness. Individual cases make great educational case studies for coding team meetings.
- Involve your CDI team: For clinical validation denials, include your clinical documentation improvement (CDI) team in the investigation and appeal process. The CDI specialists are trained to identify the clinical evidence needed to support code assignment. CDI needs to be aware of the types of cases that are not passing the payer’s scrutiny of the medical record documentation.
- Compare coded, billed and paid DRGs: Set up a computer-generated report that automatically identifies exceptions when comparing the DRG that was calculated by coding with the UB-04 data and the remittance advice (RA). Any discrepancies should be researched to determine the cause (i.e., system or payer grouping issues) and action should be taken to prevent future discrepancies.
At CloudMed we focus on coding and documentation accuracy and improvement that effect reimbursement, compliance, and the denials process. CloudMed Solutions or info@CloudMedSolutions.com
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