Denials Mgmt:
Developing a program that lasts
Oregon HFMA
Spring Meeting
M 2015
May
Michael Bennett, MBA, MHA
Director of Revenue Cycle
A t H
Asante
Health
lth System
S t
A t iis…
Asante
 A local,, communityy
owned and governed,
not-for-profit organization
 Southern
h
Oregon’s leading
l d
non-seasonal employer with
more than 4,500 employees
 A Truven 15 Top
Health System in the nation
Asante Health System
y
Asante Rogue Regional Medical Center (ARRMC) 378 beds
Asante Three Rivers Medical Center (ATRMC)
125 beds
Asante Ashland Community Hospital (AACH)
49 beds
Asante Physician Partners (APP) – more than 150 providers
in 23 locations
Joint Ventures:
–
–
–
–
–
Surgery C
S
Center
t (Medford)
(M df d)
Cardiovascular Institute
Siskiyou Imaging
Southern Oregon Linen Service
Home Health (Medford and Grants Pass)
Asante – Rogue Regional Medical Center
Regional referral center
 Only neonatal intensive care unit (NICU)
 Only high-risk obstetrical services
 Only dedicated pediatric unit
 Only
l inpatient
i
i behavioral
b h i l health
h l h unit
i
 Nationally ranked cardiac services
 Dubs Cancer Center
 Joint Replacement Center
The Communities and the People We Serve
County
Jackson
Josephine
Curryy
Douglas
Klamath
Lake
Siskiyou
Del Norte
Modoc
Population (2014)
208,375
82,960
22,355
,355
109,385
66,910
7,990
45,231
28,131
9,197
Asante Service Area
The Asante service area covers nine counties and 37,841 square
miles of southern Oregon and northern California
California, with a combined
population of 580,534 people. Asante’s primary service area is
Jackson and Josephine Counties, with a combined population of
290,675.
The Scoop
•
•
•
•
•
Focus on it
Structure
Innovative culture
Communication
Long term
perspective
Magnetism
Magnetite (Iron Oxide) – naturally
magnetic minerall
• 6th – 2nd centuries B.C. originally
“di
“discovered”
d”
• 2nd century BC to 1st century AD
compass created by
b Ancient
China
• 1824 – William Sturgeon invents
first electromagnet
Magnetism
•
•
•
•
•
Focus on it
Structure
I
Innovative
ti culture
lt
Communication
Long term
perspective
Obvious Statement #1
Insurance companies
p
are a business
….so are you.
Insurance Companies are a Business
Money in
•
•
•
•
Money out
Enroll large number of members
A
Accurately
t l predict
di t healthcare
h lth
costs
t
Process more efficiently
Reduce/Delay payment (“manage
utilization”)
Insurance Companies are a Business
How can we use this knowledge?
• Payer intentions are not changing
• Payers can be motivated in multiple ways
• Relationships
p are keyy
Food for thought
thought: It costs money each time
an insurance company denies a claim.
Obvious Statement #2
Healthcare financing is complex
Healthcare financing is
complex
l
• Multiple stakeholders (internal/external)
• Lack of standardization
• Unique consumer behavior
• Incompatible
I
tibl systems
t
• Disparate information
•
Unilateral decision
decision-making
making
•
Competing definitions
•
Moral dilemmas
Healthcare financing is
complex
l
It is crucial to simplify the complexity
• single ownership
• defined workflows
• ggood success metrics
• Standardization & specialization
• “change”
change the approach
Obvious Statement #3
Most people don
don’tt understand
healthcare billing or denials.
Most people don’t understand
healthcare billing or denials
Neither of these
groups actually
decides what care
is given
Most people don’t understand
healthcare billing or denials
How to help them understand?
• Acknowledge
g ALL of yyour
stakeholders
• don
don’tt try to treat everyone the same
• define & educate
• invest in training & talent
l
(SME
(SMEs))
Obvious Statement #4
D fi i the
Defining
th problem
bl
iis h
half
lf th
the b
battle.
ttl
Denial definition: any delay or reduction in payment.
Common Goal: prevent denials and/or resolve them
more quickly.
Obvious Statement #4
Rainbow Trout
Obvious Statement #4
You never have to fight a current if
you never go downstream.
d
t
• Take time to build common
understanding
d
d
• Focus resources where you want
the changes to occur
• It’s okayy to be creative in yyour
solutions
• Make it work for your organization
Get your house in order
•
•
•
•
•
Inefficient routingg of work
Lack of specialized expertise
Inaccurate information from payers
Lack of compliance with P/Ps
No formal feedback mechanisms
Get your house in order
Denial status evaluation – PI project(s)
• Document
D
current workflows
kfl
• Review reports & transactions
• Standardize
S d d reason and
d remarkk codes
d
• Update categorizations and routing rules
• Update
U d t workflows
kfl
and
d P/Ps
P/P where
h
needed
d d
• Ongoing education on appropriate actions
• Consistent
C i t t auditing
diti
Get your house in order
Denial Automation:
• denial impact indexing
• elimination of non value-add work
Electronic statusing:
• 276/277 responses
• screen scraping technology
• scripting vendors
Get your house in order
•
•
•
Understand
U
d t d hhow Remark
R
k codes
d are usedd with
ith goall to
t
auto-completing requests
Partner with payers to develop improved Expand Line
Item Postings
Developp internallyy Line Item Adjustments
j
– so we can
attribute adjusted dollars to denied charges accurately
The Payer relationship
• Relationships
p are Keyy
–
–
–
–
Regular, face to face, interactions
Include ALL keyy stakeholders
Clear communication & expectations
Strong contracts
The Payer relationship
• Motivation
– Individual relationships
– Processes
• Cost Saving ideas
• Risk Sharing
The Payer relationship
• Common Understanding – “in the weeds”
–
–
–
–
Record request matrix
Remit code reviews
Escalation lists
Track & Discuss Third Party Auditors
Simplify the complexity
• Single
g Ownership
p
– Well defined success metrics
g
point
p
of contact
– Organizational
– One leader = consolidated vision
Simplify the complexity
• Success Metrics
–
–
–
–
–
–
Cash Pmts
j
Adjustments
% Claims denied
First pass denial rate
Avg touches to resolve (denial vs non-denial)
Agings (91+ , etc.)
etc )
Simplify the complexity
• “Change
Change the Approach
Approach”
–
–
–
–
More strategic, less account by account
Introduce your front line team to analytics
Specialization of staff, top of license work
More oversight and more “task
task force
force”
initiatives
Simplify the Complexity:
Root Cause Analysis Realities
Right people in the right roles
•
•
•
•
Need effective “identifiers”
identifiers
Need effective “champions”
Not all issues are “correctable”
correctable
Learn to maintain enthusiasm for longer
term initiatives
Know what you don’t know
• Define & Educate
– Evaluate organization definitions and
maintain consistency in terminology
– Take the time to properly educate all
levels and areas of the organization
(
(new
leader
l d orientation,
i t ti leadership
l d hi
training sessions, etc.)
– Goal
G l iis tto establish
t bli h a common
language
Know what you don’t know
• Invest in training & SMEs
–
–
–
–
System efficiency
Workflow & process
Escalation methods
Specific denial/appeal skill sets
Know what you don’t know
• Acknowledge ALL stakeholders
– Don’t treat everyone the same
– Don’t
D ’t exclude
l d anyone ffrom th
the conversation
ti
– Engage the provider community
(physicians & others)
Truly engaging clinical staff
Key Points:
• Most clinicians will not intentionally cause
denials
• Hospital denials will NEVER be the #1
priority
i it ffor a clinician
li i i
Truly engaging clinical staff
Key Points:
• Work closely with physician leadership
• Engage
E
operationall leadership
l d h
• Target mid-levels and support staff
• Use your technical resources (EMR alerts,
ggrease boards,, etc.))
Put resources where it matters
Put resources where it matters
•
•
•
•
Pre-service resources
System optimization
Process engineering
R
Revenue
cycle
l specialists
l
Be Creative
•
•
•
•
“Claims Attachment” program
Denial “Diodes”
Diodes
Highly skilled coders
D
Denial
l prioritizations
Michael Bennett, MBA, MHA
Director of Revenue Cycle
A t Health
Asante
H lth System
S t
Contact Information:
Phone: 541-789-4791
Email: [email protected]