Payer-provider friction is a reality for every healthcare delivery setting. At larger organizations, this can mean significant loss in revenue, but with a solid strategy and a dedicated focus on process improvements from key subject matter experts, payer-provider friction can be reduced. The organization in this case study—a large, integrated health system comprised of six hospitals, over 44,000 employees, and 11 multispecialty centers that is consistently ranked in the top 15 on US News & World Report’s best hospitals list—established a professional fee denials prevention workgroup. The objective of this workgroup is to review denial trending data for opportunities to ensure payers are billed appropriately the first time, identify situations where that isn’t occurring, and confirm the payer is making an inaccurate denial determination.
Co-led by the organization’s associate vice presidents in patient accounting and revenue operations, the 50-plus members of the workgroup include analysts, coordinators, managers, and directors from information technology (IT), physician billing office, professional fee coding, scheduling and registration, and department/division revenue integrity, among others. A team of IT application developers created an internal tool called WatchDAWG to track and trend denials data over time and provide the workgroup members the capability to drill down into denials from various payers.
The workgroup was developed in 2019 with the objective of reducing denials by identifying, addressing, and effectively closing gaps in internal processes, and partnering with payers when they deny claims inappropriately.
The initial process is simple: assess denial codes and assign owners to them; review denials data for trends; investigate trends for root cause; report findings and recommendations to the workgroup; and determine next steps to reduce or eliminate the issues contributing to the denials. The health information management team owns the denial categories focusing on coding and bundling, and progress has been remarkable.
The workgroup has been able to review trends for services at one hospital and identify the lack of trends for the same services at another hospital for patients with the same health insurance. Some of these denials are based on payer rules that differ from payer to payer and require the help and support of resources and technology to help navigate these variances in plan rules. For example, one health plan may pay for a pre-procedure electroencephalogram (EEG) listed on a claim along with the procedure, whereas another health plan bundles the EEG into a payment for procedure and doesn’t want to see the EEG reported on a claim separately. Therefore, when the EEG is performed for a patient with Health Plan A, there needs to be a process built that puts the EEG CPT® code on the claim, and when the EEG is performed for a patient with Health Plan B, there needs to be a process built to remove that EEG CPT® code from the claim. If the EEG CPT® code is not removed for Health Plan B, the entire claim may be denied.
Some of the workgroup’s early wins have been the identification of solutions that can be realized through automation. The addition of billing system edits, leveraged by payer contracts, help ensure services that were being provided but were not eligible for reimbursement by certain payers were stripped off of claims in advance of the claim being sent to the payers. The workgroup also wanted to be able to track and trend the service being provided. Through collaboration between subject matter experts, the workgroup has made this a reality.
Bringing leaders from each group together to troubleshoot and talk through department processes has been a successful approach to denial reduction and process streamlining. Quarterly newsletters distributed to leadership with regard to team denials reduction and first pass yield increases have been beneficial to the workgroup at large as well as the organization.
Results and Next Steps
At the beginning of the journey, using comparative benchmark data, the workgroup was in the mid- to low-region of its peer group. In two years, the team effectively moved its position seven spaces up to the mid- to high-region in relation to its peer group with first pass yields. This occurred by implementing new processes to ensure clean payable claims are being sent to payers from the billing office. The group implemented a new data mining and reporting tool to help facilitate denial data review. A newsletter has been developed to share the team’s successes with internal stakeholders. Relationships with various payers have improved, as well. The relationship between provider and payer is like most relationships and requires trust and effective communication. The team is putting in the time and effort to ensure appropriate billing occurs, and payers see that. But in order to reduce payer-provider friction, that work needs to be communicated to payer liaisons, and errors the team identifies for the payers can be communicated and addressed.
Throughout this past year and a half, the organization’s workgroup, as well as the team contributing to the workgroup efforts, have learned many lessons and pivoted strategy and work efforts based on those lessons. The team initially had two dedicated management resources dedicated to this work effort; it determined that while their expertise is extremely beneficial, their time and effort needed to be spent elsewhere. The team moved the ownership and routine participation from two managers to a coordinator, with support from a team analyst. This partnership has proven to be a very effective change. The coordinator is both AAPC and AHIMA credentialed and possesses vast coding and billing knowledge. Her partnership with the analyst to identify trends in CPT® codes, diagnosis codes, department, division, entity, provider, payer, etc., has been exactly what the workgroup needs from the team.
The team has also learned that cleaning up its own business processes helps in the communication with payers when there are concerns about their adherence to their own payer rules and input to change the rules during contract negotiations. It takes regular attention to the billing data in order to have meaningful communications with payers to ensure appropriate reimbursement follows.
Tami Montroy is the director of professional fee coding at a large health system.