How Providers Are Crushing Claims Denials

Revenue-cycle teams apply new approaches to old problem

Teamwork and vigilance are key components of minimizing claims denials at health systems, hospitals, and physician practices, according to two finance executives who participated in a recent HealthLeaders Media Roundtable event. Their remarks were posted on the HealthLeaders Media website

“For me, a [claim] denial is a failure in some upstream process. Taking care of denials can be like swatting flies when you should be shutting a window somewhere,” said Krishna Ramachandran, chief administrative officer at the DuPage Medical Group (DMG) in Downers Grove, Illinois.

Since DMG was formed in 1999, the organization has been using health care information technology to optimize several revenue-cycle capabilities, including claims administration, Ramachandran said.

“What we have been doing is investing in technology. We took all the data from Epic and put it into the Tableau platform—a data visualization tool. The idea is looking at trends over time. How can we drill into certain specialties? Who are the top doctors? What are the denial causes? Shutting a window varies from case to case. Are we not pre-certifying? Are we not getting a referral somewhere?”

At the Pittsburgh-based Allegheny Health Network, the revenue-cycle team has developed an aggressive approach to reducing claims denials in collaboration with stakeholders across the organization.

“We look at how we can start from the moment a physician orders something,” said Marti Strand, chief revenue-cycle officer at the seven-hospital health system. “For example, we had an issue with inpatient-only procedures. We were able to intercept orders right from the moment doctors submit for a surgical procedure, and route that to a specific coder. We check those orders throughout the process to make sure the moment somebody tries to change an order, we act. So we can use the clinical data streams to get in front of a problem before it even begins.”

When claims problems occur, Strand’s revenue-cycle team leads a “denial crush” to find solutions to avoid future financial mishaps, she said.

“We have a big classroom that has an overhead display and plenty of seats for everybody with computer systems. We bring in payers; we bring in clinicians; our CFOs come to the meeting; the heads of departments come to the meeting; our coders are in the meeting; and Utilization Review is in the meeting. We pull up accounts together and watch what happened with them from every angle.”

The benefits of a “denial crush” session extend beyond solving claims-processing problems, Strand said.

“It is so enlightening not only to fix the denial, which we do during the sessions, but also for everybody to walk away educated about what they are doing in their departments, or from the physician's angle, or for the CFO to have a new level of understanding.”

Sources: HealthLeaders Media; June 7, 2017; and Roundtable Report; May 2017.