A successful payment denials prevention strategy requires engagement across a healthcare organization and the effective use of data and technology, according to Andy Talford and Lynne Hildreth.
They presented “Taking an Organizational Approach to Denials Prevention” on Wednesday at the HFMA Annual Conference 2018.
Such a strategy reduced denials from 14% of gross charges to 8% over about three years at Moffitt Cancer Center in Tampa, Fla., where Talford is director of patient financial services and Hildreth is director of patient access.
“We make sure everyone in the enterprise sees the big picture of denials management and what part they play in the big picture,” Talford said.
A key part of Moffitt’s strategy is a bi-monthly steering committee meeting that includes the organization’s CFO, physicians, revenue cycle directors, and other leaders, such as Talford and Hildreth. Denials data, challenges, and successes are discussed in the meetings.
“We try to ensure that the tone of the meeting is collaborative,” Hildreth said. “We’re not there to humiliate anyone. The meetings are data-driven and success-celebrating.”
Another element of Moffitt’s denials management process is a thorough root cause analysis process.
“This is where the heavy lifting occurs,” Talford said. “Individual subject matter experts receive the denials that are pertinent to their areas, and investigate the root causes. They are the best ones to review what may or may not have gone wrong with that denial.”
Having the operational people perform the root cause analysis on denials helps clear up existing denials, and helps prevent future denials, Talford noted. Furthermore, in many cases, the operational people are empowered to file the appeals of denials with payers, he said.
“This makes it a full circle loop,” Talford said. “The denial occurs, the subject matter expert receives it and reviews it, and they appeal it. So they’re involved in process improvement and revenue recovery.”
Technology facilitates the appeals process, Talford and Hildreth said. Moffit uses “robotic process automation,” which automates much of the tedious work involved in filing appeals. For example, the software uses predictive logic to determine what parts of a patient’s medical record needs to be included in the appeal, and how the appeals letter should be written. The software also reduces the data input required by auto-filling information such as the patient’s identification number.
“This has really streamlined our appeals process, and allowed us to experience a 20% gain in the amount of appeals we can do in a day,” Talford said. “Most healthcare organizations have a dollar threshold below which they won’t bother to appeal denials—we’ve dropped our threshold twice in the past two years because of our increased efficiency. We are now appealing down to fairly small dollar amounts.”
Procedures and technology are important, but the right culture is essential, Talford and Hildreth said.
“The right culture is necessary for the denials management process to flourish,” Talford said. “It’s a culture that engages every facility and department across the spectrum of the denials effort.”
