A Recent Survey by Finvi and The Health Management Academy Uncovers the Facts!

Denial management! This is probably the biggest issue for healthcare RCM organizations. Industry conferences feature speakers with recommendations on how best to manage the inevitable denials. News articles talk about everything from the growing number of denials to the multitude of ways to manage them. All that noise can create confusion and uncertainty, as it seems like everyone has a different opinion on this topic.

What most healthcare RCM organizations want to know is…what are others within in the industry doing to manage their denials! And how successful are their strategies? Let’s take a look at how leading health systems deal with denials.

Survey says…

A recent survey discovered how RCM executives currently manage denials as well as their plans for managing them in the future. And it uncovered how these leaders make strategic decisions to invest in technology to transform the back-end revenue cycle.

Despite much of the industry buzz around using automation to help manage denials, approximately 70% of leading health systems surveyed have less than one-fourth of their denials managed using automation. These healthcare RCM leaders shared that the adoption of automation for denial management has been slower because of the real and perceived complexity of denial management. Some think that denial management is too complex to leave to automation.

However, these revenue cycle leaders also recognize how automation may speed up part of the denials process. And early applications of automation have provided much-needed relief to busy revenue cycle workflows and teams. While revenue cycle leaders are in the preliminary stages of automation adoption, there remains substantial room for growth. As such, many of these revenue cycle leaders look to partners who can serve as useful collaborators. These revenue cycle partners have the experience to help leading health systems identify the optimal areas for automation.

What’s next?

Interestingly, leading health systems placed value on technology and automation capabilities in prospective partners, while qualitative data signaled uncertainty about the technology’s role in their denial management work. Leading health systems have found themselves fighting with RCM solutions that have not delivered on the promise of increased productivity. However, revenue cycle leaders also understand that emerging technologies present opportunities to be proactive in their payer relationships, which could improve revenue and timely payment.

Therefore, it is important to understand what features must be present in a denial management solution.

Automation for denial management

Any denial management solution must take advantage of RPA in a way that can be configured to handle some of the more complex tasks associated with management. Since a claim can be denied for any number of reasons, automating the process of gathering the necessary information to analyze why the claim was denied would be a critical time-saver. The solution should also be able to be incorporated into your existing workflow to help improve the productivity of your agents.

The automation should allow the solution to:

• Categorize denials into clinical vs. technical with customizable CARC code mappings for appropriate routing and follow-up.
• Configure CARC mapping by payer for workflow and root cause analysis.
• Leverage 835 EDI files to analyze CARC codes to determine the root cause and route for appropriate workflow.
• Manage appeals with workflows specific to Level 1-3 appeals through action and result codes.
• Complete RPA-driven tasks associated with:
  • Incorrect or missing information
  • Invalid coordination of benefits or no coverage
  • Additional documentation requirements
  • Adjustment postings

Additional automation

Denial management is just one of the areas of the healthcare revenue cycle that can benefit from automation. Many aspects of the entire healthcare insurance process can be enhanced through automation.

In fact, the entire health insurance process can be difficult for RCM departments. That’s because insurance providers continually change coverage, enhance their efforts to deny claims, and update enrollment requirements. Yet, automation can help overcome some of the challenges associated with this necessary part of healthcare. Let’s look at some of the other areas where automation has proven beneficial for healthcare RCM organizations.

Insurance follow-up

Leading health systems must manage the insurance process to ensure payments are received from insurance providers. Insurance follow-up is a time-consuming task that keeps RCM staff from tasks that require a human touch and help improve the patient experience. Some of the tasks that can benefit from automation include:

• Standard, exception-based workflows to automatically process accounts through follow-up actions.
• Raw file scrubbing of 835 and 277 EDI files, combining claim status and CARC codes for root cause analysis.
• Creating and managing financial treatment plans.
• Work queue management, which organizes similar accounts based on status, phase, and other criteria.
• Tools and views that allow agents to quickly navigate to payer websites.
• The ability to set payment discrepancy thresholds to streamline the working of over- and under-payments, improving accuracy and time spent working these accounts.
• Configurations that track dates, alerts, escalations, denials, and appeals for timely filings.
• Tracking, prioritization, and management of unallocated payments, which improves overall time to resolution.

Complex claims

Whether from an automobile accident, a difficult medical procedure, a workplace incident, or another situation, complex claims require additional time and resources to manage, including staff members with specific expertise in these types of claims. Complex cases often include:

• Intricate levels of details
• Multiple parties
• Legal disputes
• Large financial losses
• Settlement tracking
• Lien tracking

These cases are often managed manually, which can be marked by inefficiencies, errors, and approval delays. Yet, automation can eliminate many of these errors and inefficiencies, and can also:

• Send reminders about required documents with the ability to upload them within the application.
• Track letters and phone calls made to all parties involved in the complex claim.
• Ensure timely filings are applied to payer resolution requirements.

Program enrollment

Underinsured and uninsured individuals continue to pose a problem for healthcare organizations. Helping patients explore their options and ultimately enroll for coverage is one way to humanize the patient experience.

When it comes to program enrollment, automation can help with:

• Guided questionnaires that gather demographic, medical, household, and other program qualification details, which streamlines and automates the screening of the patient population for eligibility in charity care, Medicaid, and other reimbursement programs.
• Required documents, guiding agents through gathering all the necessary documents for program qualification.
• Tracking all program qualification rules configurable to your specified programs.
• Checking screening questionnaires against the rules engine with delivered work queues and statuses to fast-track qualified patients through the next stages of enrollment.
• Enrollment tracking, including submission dates, response dates, approval dates, and assistance in adding the new coverage to the encounter once approval is received.

Here to stay

Insurance companies have already begun adopting automation to review claims, resulting in an increase in denial rates. Therefore, healthcare providers and their RCM partners need to combat those automated denial strategies with automation of their own.

Healthcare RCM organizations that have begun automating revenue cycle tasks have discovered how beneficial this move can be for their employees, patients, and RCM operations. When it comes to denial management, automation can lead to increased efficiency, reduced operational costs, improved accuracy, and better utilization of human resources for tasks that require critical thinking and decision-making. Staff can focus on those tasks that require a human touch, specifically when connecting with and reaching out to patients.

Despite all the noise, the fact is…leading health systems are starting to use automation as part of their denial management strategy. As this tool continues to show its worth, more RCM organizations will embrace the benefits of automation. And this makes a trusted, experienced partner even more important!

If you want to learn more about how leading health systems deal with denial management and how they feel about automation, download this white paper!