Targeting Your Approach: Fighting Payer Denials in Revenue Cycle

One leader has found that using a targeted approach by creating contract experts is a key to warding off payer denials.

Regulatory burdens and never-ending denials are putting massive strains on revenue cycles, and revenue cycle leaders tend to look toward one culprit: the payer.

Why payers?

Even if your front, middle, and back-end revenue cycle is a well-oiled machine, payers aren’t shy about throwing a wrench in things. In fact, it’s not uncommon for payers to have complicated, multi-tiered structures and rules that seem to always be changing, regardless of their contracts.

Unlike Medicare, which has standard, heavily documented rationales and processes for denials, appeals, and audits, almost anything goes when it comes to commercial payers. Each payer organization will have different rules and processes, and payers’ manuals and bulletins aren’t always easy to locate.

New policy changes can be imposed throughout the year and in the mid-contract period, adding substantially to the administrative burden. Staying compliant with payers is never-ending, and with an already strained revenue cycle staff it can be hard to find extra hands, and money, to keep up.

What can revenue cycle leaders do?

One leader has found that using a targeted approach for denials by creating teams that work by payer has helped tremendously.

“My denials team works by payer,” Frank Cantrell, corporate director of revenue integrity at Penn Highlands Healthcare told the NAHRI Journal. “They know their contracts backwards, forwards, and sideways.”

Cantrell believes it’s important for his team members to be critical thinkers with a high level of understanding, which is a necessity since each payer contract has varying nuances.

In addition to being experts in their contracts, having working knowledge of the middle revenue cycle is also important. “One thing I’ve found to be key is that all of my individuals either have a clinical or coding background,” Cantrell says. He says having that extra clinical coding edge makes a huge difference in denials management.

Also, having staff with diverse backgrounds is especially helpful when writing appeal letters, according to Cantrell. It also helps their team know where to go when looking for answers. He appreciates that his team is able to determine when it’s appropriate for other departments to weigh in on a denial.

“At that point, we become more the facilitator than the actual one working the denial,” he says. “If it’s not specific to our wheelhouse, we’ll get it to the right department. I'd have to have a huge team to handle every nuance of a denial.”

If your organization is struggling with denials after creating a more targeted approach like this, revenue cycle leaders should explore opportunities to involve other departments. For example, IT can also support documentation efforts by incorporating feedback on how to improve template functions, EHR interfaces, the placement and function of drop-down menus, and other user experience and interface issues, according to Cantrell.

Having revenue cycle staff allocated by payer will surely help to stay abreast of the seemly ever-changing payer rules. In fact, Cigna has recently come under fire for its new policy requiring submission of office notes with all claims including evaluation and management (E/M) codes 99212, 99213, 99214, and 99215 and modifier -25 when a minor procedure is billed.

Cigna says it will deny payment for these E/M services reported with modifier -25 if records documenting a significant and separately identifiable service are not submitted with the claim.

Making sure your revenue cycle team is on top of their game is a must when it comes to payer denials.