Identifying and prioritizing denials is one of the biggest pain points for health systems today, according to Rob Stucker, senior vice president of revenue cycle management at Experian Health.
"When we ask CFOs or directors or VPs, 'What keeps you up at night?' one of the topics that is usually No. 1 on the list is with regard to handling denials … so that you're spending your time on what's going to give you the biggest impact," Mr. Stucker said during an Oct. 22 webinar sponsored by Experian Health and hosted by Becker's Hospital Review.
At Yale New Haven (Conn.) Health, leaders are addressing this significant challenge and driving revenue cycle efficiency with a strategy called enhanced claims statusing. Here are two key insights shared during the conversation with Mr. Stucker, lightly edited for clarity:
Mark Rodrigues, senior manager of accounts receivable: "Enhanced claims status eliminates manual follow-up tasks, lets providers respond early [and] accurately to pended-return, provider-denied or zero-pay transactions before the [electronic remittance advice] or [explanation of benefits] are processed. We went live with Experian's claims statusing in January of 2018. When we went live, we decided to create a committee for this project with revenue cycle operational managers, follow-up specialists, our system analysts, and also help from Experian.
"Our committee had three goals in mind when looking at claim statusing. We wanted a systematic way to find statuses of our claims at the payer. We wanted to know [not only] did they receive them, but [also] are they in process to pay or reject? Will the payer pend for additional information? Are they set to deny? We were also looking for a way to eliminate the transactional, or non-added value, work from our staff. We thought by eliminating the volume, we could allow staff to focus their efforts on the problem accounts that need true follow up. This would help with increasing our payment velocity — taking a proactive approach, correcting claim rejections or denials before the remit is posted will allow us to get paid quicker. "
Jennifer Amiri, revenue cycle system analyst for Yale New Haven Health: "I want to talk to you briefly about our technical build for enhanced claim status. As an organization, we decided to go with the X12277 file format for an enhanced claim status setup. That was because this file format just seemed to work better for us as an organization and what we were trying to do. As Mark mentioned before, we split the category and status code combinations into three main groupings — informational, actionable and deferrable — and we linked each of these groups to a designated code in Epic that would allow us to route the accounts to be appropriate work queues to be worked by staff.
"At the beginning of the process, we labeled everything as informational, which meant we didn't have any special routing rules in place. The accounts just followed their normal workflows. This allowed us to see the information that was being pulled into Epic and how we would be able to access it and utilize it. It also gave us the chance to run reports on our claims to see which statuses were being used by which payers. It's probably no surprise to hear that not all payers used the same status codes or that some codes are not being used as they were intended. So, this is why it was essential for us to be able to determine which of our payers are using which status codes and what their intentions were for those codes. This was the work done by the committee."
Click here to view a recording of the webinar.