In a presentation at the 8th Annual Becker's Health IT + Digital Health + RCM Meeting, Colleen Goethals, the vice president of mid revenue cycle at Xtend Healthcare, discussed the impact of denials in healthcare and how to mitigate them, as well as the significance of effective appeals.
Ms. Goethals emphasized the need for understanding the root causes of denials — which often include insufficient data and analytics, lack of automation, staff attrition and frequent payer policy changes. She also highlighted the importance of having a multidisciplinary team to review workflows, identify these root causes and implement effective solutions. Ms. Goethals further discussed the significance of appealing denials and provided tips for writing successful appeal letters. She concluded by reminding the audience about recent coding changes and the need for continuous education and system updates.
Editor's note: Quotes have been edited for length and clarity.
Key takeaways:
1. Consistent, timely review of workflows and data can help identify and address ongoing issues.
Colleen Goethals: "You have to keep doing that deep dive of what's going on, learn from it and move forward. Identify patterns that are across the board and then see if there are trends by payer, provider, specific diagnostic test, etc.. Don’t just depend on CARC codes, you must continue to drill down and analyze the entire process. For example, it might identify coding issues related to modifiers, chargemaster or a lot of other different things — but if you don't identify them, you just don't know."
2. Effective letter writing is essential for successful appeals.
CG: "You need a strong denials team to write those appeal letters, whether it is a technical denial or a clinical denial. Appeal every case where there is documentation to support that original coding. Keep the letter clear and concise. Don't go on and on, page after page — payers do not want to read through unnecessary information just to get to the point. And, be sure to have the pertinent records attached."
3. Keeping policies and procedures up to date is critical for reducing denials.
CG: "I'm still surprised at the number of facilities we go into that don't have up-to-date policies and procedures. With frequent policy changes, it's difficult to keep them up to date, but strive for standardization, have the guidelines written out and use evidence-based guidelines."
4. Identifying root causes and trends in denials is key to reducing them.
CG: "Identify your denials, understand them and where are they coming from, and then address the issue. It is very important to get a multidisciplinary team together to identify those root causes."