Denials Prevention for Health Systems
By Paul Shorrosh
Founder & CEO, AccuReg – Front-End RCM Transformation Services
- A healthcare dollar is only worth a dollar before patient service. After service, the cost to collect goes up and the likelihood of collecting goes down.
- Denials and claims management burns up most of that cost.
- It is time for denials prevention execution, not just talk.
- HOPE is not a strategy to getting paid for services provided.
In the healthcare revenue cycle industry, there’s more talk than walk when it comes to front-end denials prevention. Yet, most denials are predictable and preventable prior to patient service. The potential of transformational change lies at the front door of every hospital and doesn’t require hiring more FTE’s. In fact, it may save you some at the back side. So why don’t we see more focus and execution in scheduling, pre-registration and point-of-service registration? Because it isn’t easy, and it isn’t a core competency for health providers, much like back-end billing, receivables management and collections are also not core competencies.
For Patient Access teams to produce transformational financial results, it takes a comprehensive approach (people, process, systems) within a complex web of critical processes, each with its own set of steps that vary by payer, group, procedure, service, policy and location. The payers rules change… constantly. It seems impossible to scale this wall. But it can be done. It requires a coordinated approach to simultaneous improvement of people, processes and systems. Much like the billing side, the front-end can now be outsourced to experts who can help you get it done. This will be a game changer for those wanting a lower cost, higher return model to transforming their RCM.
Here are 10 steps to getting it done:
1. Audit your payer remits on a routine basis to identify your top denial patterns by volume and charges – this is where you find predictability. And remember – if it’s predictable it’s preventable.
2. Perform root cause analysis of the top denials by payer, service, procedure and ordering physician.
3. Stratify the top denials by root cause to focus effort on “pre-denial” situations before service delivery, and reverse engineer them into front-end prevention processes.
4. Create detection systems that will audit real-time during scheduling, pre-registration and point-of-service registration workflows. (Hint: this cannot be done effectively within your HIS/EMR system).
5. Alert the responsible employee of each pre-denial risk in real-time in an exception-based work queue during scheduling, pre-registration, patient arrival and on-site registration.
6. Provide the responsible employee with real-time guidance, resolution scripting and accountability to resolve the pre-denial.
7. Enforce resolution of pre-denials by escalating all unresolved issues to a manager in another exception-based work queue as a fail-safe.
8. Ensure the employee or manager resolves the pre-denial issue or reschedules the patient for non-urgent procedures.
9. Track and report pre-denial resolution rates by employee, department, facility and health system for goal-setting, performance visibility and accountability.
10. Partner with AccuReg to assess, automate, standardize and implement the above steps for a powerful denials prevention strategy tailored to your facility.
If you want to transform your revenue cycle performance from the front-end using a prevention-oriented approach that addresses technology, people and process change, contact AccuReg. We deliver financial results, and offer risk-sharing financial models based on performance goals achieved.
If you’re tired of paying huge invoices from RCM firms and getting minimal lift in denials reduction, talk to us about a denials prevention approach. It’s a fraction of traditional RCM services cost and produces significant financial results.