Belinda Bennett and Okey Silman

WV HFMA Spring Revenue Cycle
Workshop 2014
Belinda Bennett & Okey Silman II
Keys to reducing Denials
Tools to identify Denials
How to reduce Denials
 System Related
 Staff Related
 QA Processes
 Denial Committee
 Vendor Assistance
Monitoring and Feedback
Denial Log to track denials from payers
Rebill Logs – why are we rebilling accounts
Vendor review of Denials and issue report
Review of Authorization Denials
i.e. status billed did not mirror authorization in
RAC Denials
Install a Denial System
QA System
Automated real-time system in Registration
Manual QA System
Process to obtain authorizations, vendor or hospital staff
 Process to identify when a service is pre-certified but when in
Radiology a test is added or changed – communication between
departments and staff to update the pre-certification
 Process to ensure when a status changes for a patient that you
notify payers for new authorizations for observations, in-patient,
Flash meeting daily to review authorizations, payer
requirements, etc.
 Charge Master – possible review
 Billing System edits
 Computer System
 Identify settings that may not be correct, i.e. Revenue Code,
Billing System Edits
 Review Payer Contracts
Link to a check list for avoiding denials in
Payer contracts:
Computer System
Identify settings that may not be correct, i.e. Revenue
Code, CPT/HCPCS code, etc.
Checklist: Avoiding Denial Traps in Payer Contracts
While healthcare organizations can’t completely prevent denials through strong commercial
contract language, they can go a long way toward limiting those denials. Following is a brief
checklist to follow when examining payer contracts.
Be precise and avoid ambiguity. The clearer you are, the less wiggle room for denials.
Remove coding/billing requirements that are subject to change. If a reference to
coding/billing has to remain, then make sure language exists to ensure compliance with
the Centers for Medicare & Medicaid Services.
Prohibit (or set a time limit for) retroactive determinations.
Agree on what will be disallowed, if anything.
Be clear about what happens when there are payment policy changes. You may want to
require written notification of any changes and allow time to model those changes before
agreeing to them.
Prohibit recoupments and refund requests after a certain amount of time.
Delineate a timeframe for retroactive authorization of services.
Explicitly define timely filing and appeal limits.
Ensure contract language allows the contract to supersede other payer documents when
conflicts arise.
Prohibit any language that relies on information that only the payer can create or provide.
Avoid detrimental contract language that gives “absolute discretion” to the payer in claim
Include contract language about how “new” technology services will be paid and/or
addressed, rather than having to wait for the next negotiatio n period.
Source: Sonia Franklin, Palette Health. Used with permission.
Denial Committee reviews
Denial logs and reports
Tracking progress
Provide Feedback to all staff – scheduling,
registration, coding, and billing
Provide Feedback to Physicians
i.e. Sterilization Forms required for payers
 Authorization issues
Provider Errors
Medical Nececssity Can't ID Patient
Non-Covered Service Not Eligible
Level of Care
Not Authorized
Late Notification
Benefits Exhausted
Coverage Terminated
Other Insurance Prime
Duplicate Claim
Timely Filing
Lack of Information
Invalid Provider Number
Unbundled Code
Modifier Not Provided
Procedure Code Doesn't Match Gender
Procedure Code Inconsistent with POS
Diagnosis Inconsistent with Age, Gender, or Procedure Listed
Worked by UR or CM
Worked by Business Office, Access Services or Revenue
Payer Errors
Payment Not Equal to Claim
Payment Not Equal to Case Rate
Stop Loss Not Paid
Paid Wrong DRG
Correct % of Charges Not Paid
Invalid Fee Schedule
Incorrect Per Diem
Worked by Business Office,
Contracting or Revenue Integrity
835 posting files – need to watch how the
reason codes are being posted.
Each payer is different and may utilize a code
Each system is different and may post a reason
code differently
Claim Adjustment Reason Codes
Reason Code
Adjustment Group
CO – Contractual Obligations
Adjustment code for
mandated federal, state or
local law/regulation that is
not already covered by
another code and is
mandated before a new
code can be created.
OA – Other Adjustments
PI – Payer Initiated Reductions
CR – Corrections and Reversals
Reduce Denials
Improve Cash
Reduce Net AR Days
Get accounts paid timely without interruption

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