There are many different factors that can lead to rising audits and denials within any healthcare organization. Even when all the boxes seem to be checked, denials continue to rise. This can have heavy impacts on an organization’s revenue cycle, creating missed reimbursement for services provided to patients. Preventing denials and creating winning appeals needs a multifaceted approach that includes efficiency and optimization in every step of your workflow. Below is a deep dive into some strategies proven effective in combating growing denials.

Evaluate Your Initial Intake

A majority of hospital admissions stem from the emergency department, in which an unexpected medical condition results in a needed admission. Most insurances allow for 24-48 hours notification of admission followed by any clinical information being sent every few days by the utilization review department. This process is standard for most hospitals – registration interacts with patient, verifies coverage, notifies insurance, and clinical documentation is sent the following day. However, many denials actually stem from scheduled procedures or direct admits from physician offices. Why is that? Any change to the normal admission procedure process can bypass your registration process, which results in a denial. The following are questions to consider when evaluating your admission procedures.

Direct admit with surgery

  • Were insurance benefits confirmed?
  • Was insurance coverage terminated since scheduling?
  • Does procedure require authorization?
  • Which procedure is being performed?
  • Is it on the inpatient only list?
  • What process do you have in place to notify registration or utilization review that procedure change from what was schedule? For example, the initially scheduled procedure may not have required authorization, but after surgery started additional procedures were required.

Direct admit no surgery

  • If direct admit from PCP, how quickly does registration staff verify coverage when admitted (is the process the same at 8am as it is 5pm)?
  • How quickly can bed management inform registration of admission?
  • Who verifies admission orders? Consider inpatient vs observation – placing someone in observation status may not trigger your notification to insurance.

Direct admit as a transfer

  • Did the physician agree to accept a transfer from another facility based on level of care needs or specialty requirements?
  • Are you in-network, was insurance notified of transfer, are you higher level of care or lateral transfer?
  • Can you notify insurance while patient is in route to the hospital?

Verify Your Utilization Review or Case Management Process

Registration is your first step in mapping and testing your process workflow. After insurance has been verified and notified, the next crucial step in preventing denials is verifying that clinicals are submitted, received, and followed up on. Consider the following questions to pinpoint any gaps in your process workflow:

  • When the insurance is updated after arrival, how is your utilization department updated with fax numbers, changes to policy or clinical reviews?
  • Does the utilization department have a universal insurance portal to track uploads or are they using fax machines? Have you considered eFax to minimize loss of documentation?
  • Do you keep copies of documentation to prove clinicals were submitted?
  • After insurance receives clinicals, who follows-up on status and approval or denials of hospital days?
  • Since each inpatient hospital day must have an authorization, does the same nurse follow-up or can you assign a non-clinical staff member to follow-up on days approved and document?

Breakdown Silos Created by Systems and Software

Various changes in software systems or additions of new technology can affect your entire communication system and increase risk for denials. To combat this, verify your registration department and utilization department are documenting in the same system as your billing software. Claims submitted without authorizations are automatic denials. If utilization management received approval for all days but the claim processed for less than a full stay, ensure that staff performing follow-up have access to view utilization management days approved, authorization status, and specifications of level of care.

Tracking Your Denials

Opening the mail to find a denial or receiving an electronic notification of the denial is an all too familiar feeling. However, the timeframe to submit an appeal starts from the date of your receiving the notification, making this step as important as every other step in your denials and revenue cycle process. Identify and track where all electronic or paper denials are being filtered. Insurances can mistakenly use various incorrect or improper addresses within your organization, and having a denial sitting in the wrong department for five days can cost you thousands lost in reimbursement. Identify staff that will research the denial and assign it to the right department.

Since emails are often burdensome to track and prioritize, you should create or use a system that tracks the following important aspects to easily prioritize denials and mitigate any potential gaps in staff communication and workflow:

  • Staff member who is owning the denial
  • Date the denial was received
  • Appeal due date
  • Responsible reviewer
  • Cause of denial
  • Appeal submission status
  • Results of appeal

Revenue Cycle Team

When evaluating your denials management strategies, be aware that every member of your revenue cycle team must understand their role and responsibility in preventing denials. While many staff members feel they do not have bandwidth to add more responsibilities to their plate, remind staff that re-evaluating current processes will only help to maximize efficiency and minimize errors that cause re-work in the denials process. Investing in your denials management process can yield a significant improvement in denials overturned, while not addressing denials is a guaranteed loss in revenue. When staff see that their place of work is organized, process driven, and goal oriented to prevent denials and the additional work that comes with them, they will be motivated to use their skills to help maintain compliance, minimize denials, and increase reimbursement.

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