3 Considerations for Denial Avoidance

Imagine a scenario where a patient needs a necessary surgery like a prostatectomy due to prostate cancer. When the provider and patient decide to move forward with the surgery, it’s essential to set a precedent by talking to both the patient and the insurance company to find out what the out-of-pocket costs will be. By getting in front of the situation, you can begin to collect on services, reduce time-to-revenue, and ensure appropriate reimbursement. 

When a denial is resolved, the knowledge and data gained throughout the claims review process are vital to developing a proactive approach for denial prevention in the future. However, sometimes, claims trends are difficult to discern or are complicated. In these cases, three strategies can help you prevent a denial from happening or appeal one successfully.

    1. Find out how the claim will be paid. Payment can be calculated in several ways; a percent of the total charge, by DRG, or be calculated on a per diem. Spending time understanding the patient’s insurance provides a chance to educate both clinicians and coders and determine what documentation the payer expects. The best practice is a collaboration with the payer to ensure appropriate reimbursement. 
    2. Identify, measure, and report on your KPIs. Reporting is paramount to managing your KPIs. While an Aged Trial Balance (ATB) report should be utilized, additional trend reporting can be helpful when it comes to measurement, too. Trend reporting that references 837/835 review data shows both positive and negative trends in DRG downgrades and erroneous denials. Additionally, real time reporting that is accessible at any time allows for leadership to provide feedback on KPIs and daily accomplishments.  
    3. If you need to follow up with clinicians, ask specific questions. For example, if you don’t see particular lab values, ask the clinician what made them conduct one specific procedure. A real-world example could be a patient with biliary colic that impacts daily function, but the only diagnostic indicators are gallstones on their ultrasound. In this case, white blood cell counts can be normal, and bilirubin can be normal, and an abnormal HIDA scan would be the only accurate indicator of a problem. Without asking for clarification from the physician, a claim could be flagged and require supplementary documentation or even result in a denial. A clinician is not the first person to review the appeal for many payers, so being proactive to ensure there is sufficient explanation for what was missing or what was said should feature prominently in an appeal letter, right at the top.

There’s a saying that if it wasn’t documented, it wasn’t done. Sufficient documentation from clinical teams is critical in denial prevention. With these considerations in mind, it should be easier to take the claims process one step at a time and make sure your entire team is on the same page to reduce time-to-money and ensure accurate reimbursement.

 

Are you looking for even more information on the denials avoidance process? Check out the video below of Deborah Horne, Advent Health Partners’ VP of Operations, discussing these considerations in further detail, or get in touch with our team to discuss our denial prevention and management solutions.