Practice Management Alert

Make sure your billing team feels empowered to communicate well.

Denials easily cross the threshold from an administrative headache to a major threat to your practice’s bottom line.

But if you incorporate these easy-to-understand strategies, you’ll boost the efficacy of your revenue cycle management team’s work said experts Andrew Harding, co-founder and vice president of customer success at Rivet Health; Christine Hall, CPC, CPB, CPMA, CRC, CEMC, CEO and senior consultant at Stirling Global Solutions LLC; and Laidy Martinez, CPC, CPB, CPMA, CASCC, CGIC, CGSC, coding supervisor at Hoag Health System. Harding, Hall, and Martinez during their general session, How to Create and Manage a Denials Program, at AAPC’s February 2024 REVCON.

Answer These Three Questions

Harding recommends asking three questions when evaluating the how and why of denials: what’s happening, where’s it coming from, and what’s the resolution?

When you’re looking at a denial, the first level of reporting can be purely objective data, he says. You may see a remark code — the supplemental information on why the claim adjustment reason code (CARC) was administered; in some cases, the claim lacks information and needs bolstering from the medical record for it to be processed properly. In other cases, the reason might be a coordination of benefits-related denial, such as the payer actually being the secondary or When the remittances and EOBs come back, then you can look more deeply. There are perhaps 400+ reason codes or CARCs, which would be a lot to memorize, Harding says.

Instead, start to funnel the individual reason into categories to figure out the point of failure in the process: a bad registration or bad demographics on a patient, coordination of benefits eligibility, medical necessity, timely filing, coding, or diagnosis or diagnostic-related group (DRG) issue. You’re looking for the reason or point at which the denial might have been prevented, or at least identified.

Then you can begin the retrospective, where you figure out what you are recovering or resolving, so you know what happened — and, theoretically, can fix it going forward. If you’re seeing a bunch of denials related to diagnosis coding, you know you may need to approach the providers and coders. Checking in on the process, especially the follow-through, is just as important as identifying what went wrong.

Know Where to Go With Investigation Results

“If I’m starting to see there’s a lot of coordination of benefit denials, then I’m going to reach out to the front desk person and see if we can do some internal education to mitigate those particular types of denials. If they’re coding or modifier denials, go to the providers and see if the documentation is supporting,” Hall says.

Going to the staff members who are the pinnacle people in their respective revenue cycle can help you understand or move through that type of denial, Hall says.

“I think education and training are imperative when it comes to denials to ensure that you’re tackling them the right way,” Martinez says.

Focus on Communications Between Team Members

Figuring out how to lessen the intimidation team members may feel in approaching or addressing other parties involved in the revenue cycle is a crucial and underemphasized aspect of good revenue cycle management.

There are four key entities that are always at play in your revenue cycles and appeals process: the two internal teams, providers and the staff who work on some part of the revenue cycle, such as accounts receivable (AR) or front desk people who work directly with patients, and the two external forces, the payers and the patients.

“There’s a lot of collaboration coordination required,” Harding says. “Data can be really helpful, especially on your internal teams, as well as on the payer side of things. And the clinical and revenue cycle connection: it’s so critical that it is not a combative relationship. You have to foster trust and build the relationship between your clinical teams and your operations and revenue cycle teams.”

Remember: You’re all in the same boat and pursuing the same goal.

People who work on the provider side of billing can form relationships with those on the payer side and get some insights.

Harding suggests looking at forums, keeping an eye out for regional days where a representative from a particular payer may be willing to meet with folks, or even finding relevant social media accounts to follow. “You start to build that rapport and have someone you can come to with problems; you have a name, a contact, an email, a phone number that you can leverage, and then you can touch on some of that external side of things,” he says.