Denial Prevention Management Gina Stinson VP Managed Care

Denial Prevention & Management Gina Stinson, VP Managed Care Services © 2016 n. Thrive, Inc. All rights reserved. RV 06212016

AGENDA I. Upstream Evaluation II. Initial Denials III. Education IV. Reporting V. Formal Denial Prevention Program

UPSTREAM EVALUATION 3

I. Upstream Evaluation Ø Information Needs/Understandings Ø Operational Components Ø ü Pre-Service ü Time of Service ü Post Service Upstream Denial Risk Touchpoints

Information Needs/Understandings Your Denial Data The Why Your Operational Inputs and Outputs The Who, What, When Where and How 5

Denial Prevention vs. Denial Recovery Pre. Service Time of Service Prevent Denial Post Service Untimely Appeals/ Recovery Effort Denial Recovery 6

Denial Touchpoints/Assessment Areas Scheduling (pre-service) Pre-Op Appointment (pre-service) Concurrent/ Utilization Review (time-of-service) Billing 837/997 (post-service) Insurance & Benefit Verification Service Approvals (pre-service/time-ofservice) (pre-service/ concurrently/ retrospectively) Patient Registration/ Eligibility Screen Notification of Admission (time-of-service) Documentation/ HIM/Coding CDI (time -of-service) 835 Remits/ Paper Claims (post-service) Patient Preregistration (pre-service) Submission of Clinicals (time-of-service) DNFB (time-ofservice/postservice) (post-service) AR Mngmnt/ Retro Eligibility Untimely Appeals (post-service) 7

TRANSFORMING DENIALS LET INITIAL DENIALS LEAD THE WAY

II. Initial Denials Ø 835 Initial vs. Posted Denials Ø Analyzing Initial Denials Ø Identify Reduction Items

Denial Data: Initial Vs. Posted Initial Denials • Electronic 835 Remit Data – Multiple data dimensions: payor, payor order, CARC/RARC, claim type, etc. • Posted Denials • – 835 and paper • Real-time Information Dollars At Risk/Not Yet Fully Lost – Recovery work effort still viable • • Internal teams “date” the issue as no longer valid; may not review policies, processes, or educational needs based on assumptions • Dollars are Lost – Damage done – Possible legal recourse remains Denial Causation Variation – CAS/CARC/ RARC codes per payor assignment; not vetted – Initial denied value (gross/net) Generally Dated Information – 6 -24 months; includes current loses (i. e. , GZ modifier) – Can hinder denial prevention impacts – What’s happening today; narrows the “why” lens; identifies prevention/improvement areas – Improves cash acceleration; improves financial reporting • All Payor Sources • Denial Causation Validated – Root cause vetted and assigned

Analyzing Initial Denial Data 11

Analyze Data & Focus Items 1 2 Apply 80/20 Rule; cover 80% of count or dollars - based on strategy/objective Pivot Data 1 = Highest level top 10 data set: denial reason targeted/focus item “service not covered” Sub-Pivot Data 2 = Sorted by CARC code: description and code count or dollars 12

TRANSFORMING DENIALS EDUCATION: CRITICAL TO SUCCESS

III. Denial Education Ø Multi-disciplinary Approach Ø Roles & Responsibilities Ø Team Building and Collaboration Ø Understand Denials and Relationship Between Functions/Roles

Multi-Disciplinary Approach • Unite/grow teams via collective educational efforts • Patient flow and denial knowledge – Operational reality: assumptions rule • Bring groups together specifically for denial focused education no less than one time per year – Stakeholders, payors, players, processes, and information is constantly changing • Ensure everyone really “understands” roles and responsibilities • Create profound ah-ha moments by using real scenarios/patient examples across the service/care continuum

Why use a Multi-Disciplinary Approach? Pre-Service Scheduling, Financial Clearance, Pre-Registration, Pre-Collection, Pre-Op Time of Service Registration/Account Activation, POS Collections, Master Patient Index, Utilization Management, Care Management, CDI, HMI, Coding, Eligibility Screening, Charity Program Patient Post Service CDI, HIM, Coding, Business Office, Billing, Collections, Denials, Payment Variance, Self Pay, Bad Debt Experience Patient Satisfaction feeds Brand/Provider Loyalty Physician Satisfaction feeds Patient Volumes

Use Denial Touchpoint Areas to Build Denial Education Group and Committee Scheduling (pre-service) Patient Registration (time-of-service) Documentation/CDI (time-of-service) AR Management: 835 (post-service) Insurance & Benefit Verification Service Approvals (pre-service/time-ofservice) (pre-service/ concurrently/ retrospectively) Notification of Admission (time-of Submission of Clinicals -service) HIM/Coding (time-of-service) DNFB (time-of-service/post - service) (post-service) Paper Claims/Remits Timely Appeals (post-service) Patient Preregistration (pre-service) Concurrent/ Utilization Review (time-of-service) Billing: 837/997 (post-service) 17

TRANSFORMING DENIALS THROUGH INFORMATION REPORTING

IV. Reporting Ø Initial Denials and Focus Items Ø Denial Management Ø Ø Denials in Review Ø Denials in Appeal Ø Denials Recovered Ø Invalid Denials Posted Denials and Focus Items

What is an Initial Claim Denial? 835 Remit File Initial Denial Data Set

Analyzing Initial Denial Data • Create comprehensive dataset using no less than 3 months worth of data – Consider 13 months of data to provide a year-over-year comparative and solid trending data points to capture seasonal impacts • Are data points stable or have variation swings • Stable = controlled process • Variation = uncontrolled process • Create top 10 data views – Account and 835 denials by CARC/RARC – Ensure data is drillable 21

Initial Claim Denial Data (835) Identify Why Benchmark Data Accelerate Cash Initial Denials Cleaner Financials Correct Whys Track and Trend

Claim Denial Management Ø Ø Denials in Review Denials in Appeal Denials Recovered Invalid Denials The Why The When The Where 23

Posted Denials – Dollars Lost The Why The When The Where 24

Remember this Slide?

Other Initial Denial Upstream Options? No? Yes?

Other Upstream Initial Denial Avenues 271 Eligibility Response 835 Claim Remit Data 997 Claim Rejection *NCCI: code combinations **MUE: code quantities NCCI* MUE** Edits ALL initial denials Claim Scrubber Edits

TRANSFORMING DENIALS INITIAL DENIALS: DATA DRIVERS

V. Formal Denial Prevention Program Ø Build a Formal Program Ø Understand Process In-Flows and Out-Flows Ø Use Data to Identify Focus Items (Action Plans) Ø Develop, Implement and Monitor Action Plans

Build a Denial Prevention Program Executive Champion Define Program Charter Form Program Committee Educate Committee Members Understand Data In-flow and Out-flows Use Data to Identify Focus Item and Create Action Plans 30

Denial Focus Items • Apply 80/20 rule to data to identify focus items for prevention • Understand the denial targeted for reduction – Why selecting denial? • X% of total initial denials incurred • X% of initial denied dollars incurred • X% of posted denials incurred – Where should performance be? (i. e. , HFMA Map Keys, other level based on performance benchmarks) • Objectives – Prevent/mitigate initial denials and balance with posted denial data – Focus on recent denials: within last 90 days, no more than 6 months (except for trending and comparative analysis) • Why? This approach helps prevent assumptions and excuses that arise when a denial is dated

Action Planning Initial Analysis: Questions Target Denial: Answers • • • Who can prevent denial? • Why prevent – count/$ impact? • What denial is being prevented? • When can it be prevented? • Where can it be prevented? • How can it be prevented? What’s denying? How is it denying? Where is it denying? When is it denying? Why is it denying? – – – Policy/process not followed No defined policy/process No defined owner Lack of training/awareness No report to monitor Lack of accountability • Who is handling it? – – Policy and Procedure Process / Communication Training / Awareness Measurement / Accountability 32

Be Realistic with Action Plans 1 2 3 33

Driving Change • • Own the issue Commit to creating solution Assign denial prevention plan owner Assign team who will participate in plan solution Define when change will be implemented Define how solution will be monitored Set defined performance report out dates to denial prevention committee • Owner must report out until issue has stabilized within defined limits and item is removed from action plan/focus 34

Measuring Outcomes • • Capture benchmark data Define what success looks like Monitor performance per defined monitoring plan Is improvement occurring (yes or no) – If yes, proceed – If no, does plan need adjustment • Yes – define and implement adjustment and re-measure • Define if/when monitoring will cease: successful or unsuccessful • Report performance status to committee 35

When Sharing Action Plans & Data • Always stick to the facts… – – – – Why is the denial happening (understand process) How it’s preventable (understand process) Who can prevent it (who owns the process) What it’s going to take to prevent it (understand process, constraints, external factors) Where in the revenue cycle does change need to occur (understand process) When change will be implemented (how being fixed, education plans/materials, etc. ) How change will be monitored (data metrics, goals) Post implementation adjustments (owner/new plan) 36

“Old School” Summation • Identify focus items and develop prevention PLAN – – Define and develop remedy: Policy, Process or Both Establish performance benchmarks Define and develop education plan and materials Leverage leaders/executive champion to eliminate barriers to success • DO implement your PLAN • CHECK your performance against benchmarks; ongoing data monitoring • Take ACTION/ADJUST your PLAN to ensure what you’re DOING is working • Track and trend performance until variations are eliminated, or ongoing per for continuous monitoring purposes 37

QUESTIONS