When I recall playing tug-of-war in the schoolyard, it brings back feelings of struggle and fatigue. Despite all the energy being exerted, it seemed like you just couldn’t make up much ground. Even the rope would start to feel like part of the fight.
Amid the pandemic, the push and pull with payers over claims denials has many providers feeling similarly worn out. Unfortunately, from a revenue cycle perspective, it’s just getting started. Payers are still catching up from 2020 denials thanks to Covid-19, CMS continues to change regulations, and evolving paradigms of value-based care are raising new complexities. All the while, providers are short on resources and need to bring in every last dollar.
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As the denials landscape continues to change rapidly, providers would benefit from transforming the process of retrospective processing to one of ongoing prevention across their organizations. The transition needn’t be costly or complicated. It simply must focus on root-cause remedies for denials that will enable providers to stay one step ahead of payers, who traditionally have the upper hand. As providers bear responsibility for shouldering the burden of proof, here are some suggestions for stocking the denials-prevention toolkit to stay ahead of the game.
Surveying the audit landscape
Even before the pandemic, changes were well underway in the audit landscape. Providers saw the focus shift from diagnosis-related group (DRG) denials to clinical validation denials (CVD), a much more subjective approach that led to a sharp increase.
The Covid-19 pandemic wreaked havoc on the revenue cycle, exposing gaps that provider organizations had turned a blind eye to for many years. In 2020, payers gave a pass for various claims, and continuously changed the associated dates for code changes, creating more confusion. As the pandemic created staffing challenges, providers—who were already behind—had fewer and fewer resources to address the increase in denials. Most providers were out of reserves.
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Big changes also occurred for physicians by way of evaluation and management (E&M) codes, which complicated the environment even further. Rules got murkier, leading providers to simply write off denials that required too much rework. Denials were more of an afterthought of provider workflow—nuisances that revealed themselves at the end of the revenue cycle. Unfortunately, most providers have just tried to keep their heads above water as these factors compounded over recent years.
Even if providers submit clean claims, payers can deny them. It turns out, even payers have had a tough time keeping up with changing codes, and sometimes resort to immediate denials in response.
Again, the burden of proof is on providers who must send the detailed records and go through the entire process, even if they’ve presumably done their due diligence. It’s very important to note this trend because providers are often inclined to ignore denials due to a perception that they’ve done something “wrong.” Instead of fearing the attention the matter will bring, providers would be better served to address denials proactively and develop an organization-wide strategy that targets those pain points requiring relief.
Stocking the toolkit
Providers have opportunities, even within the current chaos. As providers seek to successfully navigate this complex and rapidly changing denials environment, using the following tools as part of a prospective approach—as opposed to a retrospective one—will be vital:
- Invest in coding team training and education. Accurate coding is the foundational basis for getting paid what you’re owed. Resolving errors as early as possible in the revenue cycle gives providers the greatest opportunity for optimal reimbursement.
- Secure physician participation in maintaining thorough clinical documentation. This will allow you to push proactive denial prevention even further upstream. Regardless of where the patient is in the care process, go back to the office visit; forms should be completed with the correct information and in a timely manner, and include hierarchical condition category (HCC) coding. From a risk adjustment perspective, accurate physician coding is integral for success.
- Implement an outpatient clinical document integrity (CDI) program. Use this to facilitate the accurate representation of clinical statuses. Of those performing surgery, there are numerous organizations that haven’t gotten there from the outpatient side. That’s a mistake; it has great value.
- Value the patient experience. As providers, it’s important to pay attention to the bills patients are receiving. Outlandish copays or inaccurate charges are unfair and poorly received. Patient satisfaction and quality are important, and accuracy certainly matters.
- Identify the biggest pain point. When providers say they can’t keep up with changing rules or that they feel generally overwhelmed by denials, it’s critical to identify the most problematic specialty or area of the organization. Where are the most dollars lost? Start by finding that revenue, and the smaller pieces of the puzzle will come together.
By embracing these tools on an organization-wide scale, providers are optimally positioned for an audit that could occur at any time. Regardless of the moves payers make, providers will be ready to respond appropriately thanks to attention paid across the entire revenue cycle and its contributors.
Furthermore, providers must have a realistic strategy. Remember, in the tug-of-war game, energy exertion alone did not yield a win. Strategic, thoughtful, coordinated moves by teammates working together did. Providers must use the same strategy.
By engaging various stakeholders and departments throughout the organization, providers can achieve a clinically integrated revenue cycle (CIRC) that captures a holistic view of the patient care journey. Clinical assessments and financial considerations are no longer siloed, but rather work in tandem to achieve common goals. This translates not only to healthier revenue cycle management, but the delivery of quality value-based care—the future of healthcare.
Photo: designer491, Getty Images
Geoff New is vice president of provider solutions and revenue cycle for Ciox Health. He is also an American Health Information Management Association (AHIMA) fellow.
