Providers across the country face challenges, but none are more important than determining a denial management strategy within a revenue cycle. Payers deny claims for a variety of reasons. Listing the justifications for this is a topic for another time. However, one could easily point to the stock market indexes and make a case that the justifications – or the proof – is in the pudding.

That aside, denial management challenges are a growing reality for many providers. Recent data shows insurance claim denials costing hospitals $262 billion annually. One could easily look to that example and say providers versus payers is the modern-day version of the Washington Generals versus the Harlem Globetrotters. The game is rigged, and one team is winning.

Building the right team

Investment in denial management solutions, structures and processes is vital. Structures include technology, but technology alone is not the answer. It must include an organizational chart with defined expectations and people with the necessary experience to achieve specific goals.

This centralized denial team is not a fresh concept. However, very few organizations reach the pinnacle of what is possible. Instead, they may have:

  • centralized denial management staff who lack necessary experience to successfully navigate denied claims
  • denial management task force in place of a truly centralized team
  • lack of formal training that even if provided lags the pace of employee turnover

women working together in office

To successfully address the denial management process, it is imperative that healthcare organizations invest in a team with diverse experience. The ideal team would consist of individuals with expertise in case management, coding, revenue integrity, patient access, billing, and physician documentation. Also, they would all report to the same team with one person overseeing communication, work flow, and reports.

So, what is preventing an idea that is universally accepted to succeed? Quite simply, money.

Experiencing a return on investment

Competitive salaries and formal training are lacking, and new positions are often not created due to budget constraints. In our experience, leveraging partners with unique expertise to manage denials related to coding and clinical validation provides a significant return on investment.

In fact, according to a Black Book Report, outsourced solutions are on the rise. Approximately 83% of hospitals currently outsource some accounts receivable and collections. In physician groups with 10 or more practitioners, 68% outsource a combination of collections and claims management. The benefits include:

  • more time for department leaders to manage functions and people they oversee
  • drastically higher overturn rates through leveraging experts with a focused purpose
  • independent reporting to help with root cause and data analysis
  • non-biased feedback to negotiate payer contracts and for best practices for specific cases/situations

Hospitals have made million-dollar investments into electronic health records (EHR) and bolt on technologies aimed to assist the denial process. In too many cases, imperfect workflow builds within EHRs and patient accounting systems are the genesis of the problem.

The required knowledge to fine tune those systems and maximize hospital investment is the often-overlooked component of the equation.

Empowering the players

Yes, there are cases where the necessary playbook needs work. In all cases however, hospital leaders continue to trot out the same lineups against the Globetrotter payers. They then escalate that reality by failing to empower their players with the essential education and information required to compete against those organizations.

To overcome these challenges, organizations must evaluate the sum of their parts. They must create specific roles to own the various pieces of the denial process. This includes a point guard to manage the process and streamline communication. On occasion, they’ll also need to pull an expert off the bench. This means partnering with an organization that specializes in appeals or other area of expertise that can’t be obtained internally.

Providers do have options, but each of those options requires investment in people. Hire, educate, and train or outsource to an expert. The value of human intellectual capital provides exponential return. Posting the same job descriptions with the same salary and accepting the same level of talent has and will continue to cost providers billions.

Maybe providers are doomed to play the role of the Washington Generals. The odds are stacked against them, and they have the societal responsibility of providing care. I am cheering for them to at least keep the score close. At Harmony, we work extremely hard to help them maximize the investments they have and will make in the future.

basketball goal

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