Engaging in 'denials management' rather than 'denials prevention' is a costly approach.
Anthem Blue Cross and Blue Shield is changing prior authorization requirements for some cardiovascular services for Medicare Advantage members effective August 1.
Such changes happen all the time across a wide array of payers, but unless you actively monitor their websites or read every notice that crosses your desk or drops into your email inbox, you'll miss them.
As revenue cycle leaders know, it’s hard to constantly monitor payer websites, and often they learn about changes the hard way, by getting a denial.
Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro, says that providers should allocate time to monitor payer websites.
"In reality, it is difficult to find time to keep an eye on all payer sites," she says. "On the other hand, CMS is easy to monitor once you know how to navigate their sites and what to sign up for to stay up-to-date. In most cases, there is a logical process to follow when researching Medicare questions."
But what about all those other payers? Mackaman has four tips for keeping up to date:
- Read the notices: Sign up for policy change notifications and email updates through a payer’s website, when possible.
- Set a schedule: Schedule regular reviews of payer websites. "To be successful, the monitoring procedure needs to be established and become routine," Mackaman recommends. Engaging in "denials management" rather than "denials prevention" is a "costly approach," she says.
- Prioritize: "Each facility has the ability to know who their high-volume payers are and who they have contracts with. At a minimum, monitor those payers for changes," Mackaman says. The same is true for high-volume services. "Any high cost/high volume services that each facility provides should be monitored for specific payer policy changes. First, focus on services that have the highest negative financial impact if denied," she says.
- Train and delegate: Mackaman acknowledges that figuring out who should monitor these changes is a challenge, especially in smaller facilities with limited staff. That's why identifying the most appropriate person and providing training and ongoing education is important. “Knowing where to start can be overwhelming; however, an organized and methodical approach can only add to a facility’s revenue integrity program," Mackaman says.
Alexandra Wilson Pecci is an editor for HealthLeaders.