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How Providers Are Crushing Claims Denials

News  |  By Christopher Cheney  
   June 07, 2017

Revenue-cycle teams in healthcare are applying new approaches to tackle an old problem—claims denials—according to a pair of finance executives who participated in a recent HealthLeaders Media Roundtable event.

Teamwork and vigilance are key components of minimizing claims denials at health systems, hospitals and physician practices.

"For me, a denial is a failure in some upstream process. Taking care of denials can be like swatting flies, when you should be shutting a window somewhere," says Krishna Ramachandran, chief administrative officer at Downers Grove, Illinois-based DuPage Medical Group (DMG).

DMG is a physician group that features more than 560 primary care and specialty physicians, with most patients drawn from Chicago's western suburbs.

Since DMG was formed in 1999, the organization has been leveraging healthcare information technology to optimize several revenue-cycle capabilities, including claims administration, Ramachandran says.

"What we have been doing is investing in technology. We took all the data from Epic and put it into the Tableau platform—a data visualization tool. The idea is looking at trends over time. How can we drill into certain specialties? Who are the top doctors? What are the denial causes? Shutting a window varies from case to case. Are we not pre-certifying? Are we not getting a referral somewhere?"

At Pittsburgh-based Allegheny Health Network (AHN), the revenue-cycle team has an aggressive approach to reducing claims denials in collaboration with a range of stakeholders across the organization.

"We look at how we can start from the moment a physician orders something. For example, we had an issue with inpatient-only procedures. We were able to intercept orders right from the moment doctors submit for a surgical procedure, and route that to a specific coder," says Marti Strand, chief revenue cycle officer of the seven-hospital health system.

"We check those orders throughout the process to make sure the moment somebody tries to change an order, we act. So we can use the clinical data streams to get in front of a problem before it even begins."

When claims problems occur, Strand's revenue-cycle team leads a "denial crush" to find solutions to avoid future financial mishaps, she says.

"We have a big classroom that has an overhead display and plenty of seats for everybody with computer systems. We bring in payers, we bring in clinicians, our CFOs come to the meeting, the heads of departments come to the meeting, our coders are in the meeting, and utilization review is in the meeting. We pull up accounts together and watch what happened with them from every angle."

The benefits of a "denial crush" session extend beyond solving claims-processing problems, Strand says.

"It is so enlightening not only to fix the denial, which we do during the sessions, but also for everybody to walk away educated about what they are doing in their departments, or from the physician's angle, or for the CFO to have a new level of understanding."

View the complete HealthLeaders Media Roundtable report: Innovative Approaches to Optimizing Revenue Cycle Operations at Healthcare Providers

Christopher Cheney is the CMO editor at HealthLeaders.

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