Denial Prevention – Best Practice By Melissa Blank-Harbert, Vice President & Nancy Binder, Executive Director Denials

Documentation is key to Denial Prevention

Denial Prevention – Best Practice Agenda: Denial Reasons / Root Cause Observations and Root Cause Analysis Recommendations for Improvement Data management/Leveraging Technology Top Reasons for Avoidable Denials Top Focus Area’s for Denial Prevention Trends in Clinical Denials DRG Reassignments Readmissions Questions

Denial Reasons / Root Cause Registration/Eligibility Duplicate Claim/Service Service not covered Missing or Invalid Claim Data Authorization/Pre-certification Medical Necessity Medical Coding Untimely Filing Coordination of Benefits

Where do denials originate? Patient Access Registration Insufficient documentation Coding/Billing Errors Utilization/Case Management

Observations and Root Cause Analysis Interview Staff involved in Denial Management Assess current denials management process Compare with Industry Practices and Standards Conduct analysis by trending of data Determine Root Causes on denials Perform analysis of write-offs due to untimely filing and identify opportunities for resolution

Recommendations for Improvement Set performance goals and target for denial management Create trending reports Denied Days per Admission Denials by Service Area Denials by Physician Track Avoidable Days and Review Escalation Policies for Resolution Identify Avoidable vs Unavoidable Denials Implement quality assurance process to review clinicals sent to payers for appropriate level of care and completion of clinical information Interface of systems that house authorization information

Data management Data Analytics: Denial Rates by Payer Denials Rates by Service Line Denial Rate to Zero Pay Denial Rate to Partial Pay Denials Overturned by Appeal Denials Overturned by Peer to Peer: Partial and/or All Days Denial Write-Offs Rate and Causes Percent of 1 and 2 Day Stays Percent of Low Weighted DRGs Percent of SOI/ROM (Severity of Illness/Risk of Mortality) Decrease in CMI (Case Mix Index) Case with decrease CC/MCC (MD documentation or Diagnosis Issues

Leveraging Technology Workflow and Queus to enhance productivity Real time scorecards and Adhoc reporting Service line profits and losses Automate in order to increase productivity Implement hard stops within your systems or eMR to improve documentation Use Natural Language Processing to scan records for multiple procedures performed to determine modifier needs Access Legal Guidance if Needed Hard Stops for surgical codes that are on the inpatient-only list

Top Reasons for Avoidable Denials Clinical’s not submitted Insufficient Clinical’s Documentation does not substantiate level of care These can lead to denied request for Authorization = Denied claim Clinicals should be sent every 1 – 2 days Clinicals should be comprehensive with Milliman or Interqual guidelines Physician documentation is key for defined medical necessity

Top Focus Area’s for Denial Prevention Emergency Room Admissions Make sure they know the level of care for Admissions Standardized communication between physician’s and nurse case managers Continued training regarding inpatient criteria Operating Room – Elective surgeries Documenting inpatient admission on outpatient procedures Common for Operating Room nurse to do scheduling Not typically staffed with nurse case managers Continued training for CMS admission criteria

Trends in Clinical Denials DRG Reassignments Four trends have been growing in volume and difficulty to resolve related to DRG reassignments: DRG Downcoding DRG Changes Improper processing of the DRG on the claim Denial of the inpatient DRG Readmissions – good guys or bad guys?

Trends in Clinical Denials: DRG Reassignments DRG Downcoding: DRGs can have up to 3 levels assigned which vary based on the severity of the case – DRG XXX with MCC, CC or w/o MCC or CC Method 1: Payors are regrouping the diagnosis codes and removing either an MCC or CC codes to drop the DRG value Method 2: Payors disregard an MCC or CC codes as not being a factor in the LOS/claim

Trends in Clinical Denials: DRG Reassignments

Trends in Clinical Denials: DRG Reassignments Examples of MCCs and CCs being removed to lower DRG value: MCC: A41.9 Sepsis, unspecified organism E43 Unspecified severe protein-calorie malnutrition I50.21 Acute systolic (congestive) heart failure J69.0 Pneumonitis due to inhalation of food or vomitus N17.9 Acute kidney failure, unspecified CC: D62 Post hemorrhagic anemia J96.11 Chronic respiratory failure with hypoxia I48.4 Atypical atrial fibrillation N39.0 Urinary tract infection, site not specified Z68.41 BMI 40.0-44.9, adult

Trends in Clinical Denials: DRG Reassignments How to get DRG Downcoding reversed: Must have a method of identifying when the downcoding occurs The EOB does not always outline what diagnosis code was removed Once identified, clinical documentation needs to be collected to support the MCC or CC code that was removed to submit an appeal It is important that your appeal requires a licensed clinician reviews your appeal – not a customer service representative.

Trends in Clinical Denials: DRG Reassignments DRG Changes: Payor will “re-group” the diagnosis codes on the claim The sequencing of the diagnosis codes is altered.  Mostly done on medical claims, taking the submitted DRG from a more intense DRG to a less intense one with a lower RW Physician documentation is key

Trends in Clinical Denials: DRG Reassignments DRG Change example: How to get DRG Changes reversed: Must show the DRG billed was not paid Focus on the order of the diagnosis codes on the bill – check the EOB! ER notes are very helpful to show the sequencing of the care It is important that your appeal requires a licensed clinician reviews your appeal – not a customer service representative.

Trends in Clinical Denials: DRG Reassignments Improper processing of the DRG on the claim: The claim is billed as a surgical DRG but it is processed as a medical DRG.  The payor does not acknowledge the surgical procedure codes Examples:

Trends in Clinical Denials: DRG Reassignments How to get DRG paid as billed: Easiest appeal to win! Appeal needs to highlight surgical procedure codes Point out revenue code 360 on the claim It is important that your appeal requires a licensed clinician reviews your appeal – not a customer service representative.

Trends in Clinical Denials: DRG Reassignments Denial of the inpatient DRG: On the rise for short stay (< 3 day) medical claims Inpatient claim denied but payor offers to process claim as an outpatient 2 midnight rule has not had the desired effect Do not get caught with a compliance issue

Trends in Clinical Denials: DRG Reassignments Common DRGs denied for IP stay

Trends in Clinical Denials: DRG Reassignments How to appeal denials of short stays: No easy answer! Answer is in the management while in house or case management in the ED Consider billing 12X to get something paid Cite the 2 midnight rule if stay is at least 2 days Utilize tools like Milliman or Interqual to justify stay

Trends in Clinical Denials: Readmissions Medicare watches all readmissions < 30 days from discharge Some payors have shorter windows If shown to be a related case, the claims are combined Commercial payors are known to deny second admission entirely So are readmissions a bad guy or good guy?

Trends in Clinical Denials: Readmissions The answer is both…. Bad guy: A readmission can indicate the patient was discharged too soon Medicare tracks readmissions and a high rate can penalize reimbursement based on quality concerns A high rate can negatively impact a facility’s expense per Medicare recipient metric A high rate would can also warrant a safety concern from Medicare

Trends in Clinical Denials: Readmissions The answer is both…. Good guy: For commercial payors, combining accounts can take an account over a stoploss provision and render a higher payment – don’t miss this opportunity! Best Practice: Avoid readmissions – bad outweighs the good Document scheduled readmissions

Melissa Blank-Harbert, Vice President: mblank@patientaccounts.org Nancy Binder, Executive Director: nbinder@patientaccounts.org