3 RCM Strategies to Improve Denials Management

In HealthLeaders’ latest The Winning Edge webinar, WVU Medicine’s Beth Carlson explains how revenue cycle management leaders can improve denials management to not only prompt better and quicker resolutions, but reduce denials before they even occur.

Denials are a key pain point for revenue cycle management leaders, and a problem that affects the entire organization, from patients on through to providers. But today’s RCM executives don’t have to go it alone in addressing this problem.

Through collaboration with other departments, such as clinical, and the use of technology like AI, RCM leaders can move upstream and proactively address denials even before they occur. They can also better prepare for when denials do occur, and work with payers to understand and improve the process, reducing expensive and time-consuming appeals and ensuring that patients receive the care they need.

In this week’s HealthLeaders The Winning Edge webinar, titled “Defeating Denials,” Beth Carlson, VP of Revenue Cycle at WVU Medicine, explains how today’s RCM departments aren’t just a back-office function of the healthcare enterprise, and that they’re much more involved in helping patients get the care they need by addressing and improving denials.

To fully embrace this strategy, Carlson offers three pieces of advice:

Establish a Strong Denials Management Process. Create a framework not only for addressing denials, she says, but also understanding why they happen and how they might be avoided.  Study payers to understand when and why they issue denials, even spotting trends with certain payers and delaying tactics; work with providers to examine medical necessity and care pathways, helping them to understand when a certain procedure or process might go against a payer’s policies; and even work with patients so that they understand their benefits and options for care.

When denials do occur, start with a root cause analysis to understand all the factors of that particular denial, and be ready to to establish a “triage escalation capability” if a denial is particularly complex. Make sure service lines—clinical, financial, legal—review them as well, so that everyone understands why they happened.

Collaboration is Key. RCM can’t happen in a vacuum any more, Carlson says. It’s crucial that RCM leaders work with other departments to both understand denials and address them after they happen.

Working with clinicians will help both RCM staff and clinicians to better understand how denials happen. Clinicians can then develop care pathways for their patients that steer clear of procedures that would be denied by payers, and RCM staff can identify and work with clinicians who cause frequent denials. In addition, there are occasions when a doctor can prove to RCM leaders and even a payer that a certain policy isn’t working, and can help to have that payer change the policy to reduce denials.

Looping in the legal department is important as well. They can help RCM leaders develop strategies to speed up the denial resolution process, including understanding when a case is too complex to pursue.

And finally, working with patients at the earliest point in the healthcare journey—before the patient even comes into the hospital—can benefit everyone. Educating patients on their financial responsibilities, health plan coverage and other details of the care experience can reduce the chances of an unexpected or surprising cost down the road. This also gives RCM leaders and staff and opportunity to better understand the patient’s care journey, and to work with patients on a care plan that synchs with their insurance coverage and policies and reducing the chances of a denial.

It’s All About the Data. As with almost any facet of the healthcare enterprise, data is the key to improved performance and outcomes, and with today’s technology (especially AI), there are many more opportunities to access, manage and find value in data. With denials, this means gathering all the necessary information ahead of time on payers, providers and patients.

Carlson says RCM leaders need to understand the data and how they can use it—and how to use AI tools to get the most out of that information. They can better understand payer policies and trends, identify coding mistakes and opportunities, and gain insight into provider tendencies and care pathways that lead to denials.

That data comes in handy when dealing with payers as well. RCM leaders who are armed with the right information can not only smooth the denial resolution process, but work with payers to identify improvements (in either provider practices or payer policies) that can reduce denials and improve patient care and outcomes.