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How Providers Are Crushing Claims Denials

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."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.

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