As national payers implement discretionary coverage policies for emergency department and hospital-based imaging services, hospitals must revamp their claim denial action plan.
Proactive hospitals are reassessing claim denials by aligning utilization revenue teams with revenue cycle management personnel, ensuring accurate coding at patient scheduling and deploying RCM experts to train front-line staff. Nathan Hughes, senior director of RCS utilization review at Winston-Salem, N.C.-based Novant Health, and Ed Gaines, chief compliance officer of Carmel, Ind.-based RCM service provider Zotec Partners, offered strategies to overcome payer denials at the Becker's Hospital Review 3rd Annual Health IT + Revenue Cycle Conference in Chicago.
Here are three ways to prevent claim denials.
1. Employ "instructural designers" to train patient access representatives. The key to preventing claim denials is an accurate current procedural terminology code at the time of scheduling, Mr. Hughes said. Deep processes and multiple safety nets must be present to ensure schedule procedures match performance and billing codes. A constant hindrance to proficient coding is high turnover of patient access representatives, especially in the ED, Mr. Hughes noted. To combat this, Novant Health has a revenue cycle education team staffed with higher education experts, or "instructural designers," to develop content for adult learners and cultivate staff buy-in.
2. Encourage front-line partnerships to curb medical necessity denials. Physician partnership is vital when reducing medical necessity denials, Mr. Hughes said. While tying a line of communication between a CMO and physicians is constructive, the best way to address medical necessity denials is forging connections between service line leaders and physicians within a specialty, he noted. Service leaders can then approach physicians on a peer-to-peer basis about specific metrics leaving reimbursement on the table each year.
3. Make staff experts in new coverage policies. As discretionary ED and hospital-based MRI and CT scan coverage is "becoming a bigger issue" for RCM departments, Mr. Gaines said administrators must rethink how they train staff on differential diagnoses. Successful RCM departments will dive into an explanation of benefits with employees and scrutinize each step that led to the claim being classified as nonemergent and denied. Mr. Gaines added this process will become more streamlined as hospitals automate coding and provide physicians specific feedback.