Ann Chandler FHFMA CHAM Michel Roche, Jr. CFC Sherri Creech CHAM CPAR Team-D (Transferring Expert Analytics into Managing Denials) Gwinnett Health System’s in-depth look at teamwork within the Revenue Cycle to decrease denials. Ann Chandler FHFMA CHAM Michel Roche, Jr. CFC Sherri Creech CHAM CPAR

TEAM “D” Transforming Expert Analytics Managing Denials

Denials can cause havoc on your A/R.

Ongoing Mission Consistently reduce denials that may lead to write-offs by identifying trends, root cause, addressing payer issues, and implementing process improvements throughout GHS’s revenue cycle.  Goals - Through the combined efforts of its members, the SWAT teams’ primary goals are:  Reduce the frequency of denials Minimize avoidable write-offs Increase total cash collections. 

Denials Management & The Revenue Cycle It takes collaboration from the entire Revenue Cycle to manage denials that potentially could lead to write offs. The team should consist of experts from these departments: Scheduling Patient Access Preauthorization Coordinated Care HIM Revenue Integrity Patient Accounts Reporting & Analytics

Denial Management Process Multi-disciplinary team using S.W.A.T. approach (Strategic Working & Analysis Tactics) Strategic Working Dedicated Denial Management Care Supervisor in Patient Accounts Each CAS Codes on a remittance advice is assigned and owned by a Revenue Cycle department Bi-weekly reporting of denials to each area for their review Analysis Tactics Monthly Denial Team meeting Each area provides feedback on their CAS code review Root Cause analysis of high volumes and high dollars Department accountable for process improvement actions

Denial Management Focus GHS has been able to easily identify trends and target these denial categories: Registration/Eligibility Authorization/Pre-certification Medical Necessity & Level of Care Medical Coding Charge Validation & Auditing Medical Documentation Requests Timely Filing

Denial Categories

Payer Mix

Denials by Area/Ownership

Scheduling Surgery Scheduling Centralized Radiology Scheduling Centralized Decentralized Scheduling Cardiology Pain Management OTC Sports Rehab

Insurance Scheduling Grid

Preauthorization Using this backend denial reporting, Preauthorization has identified: Areas for improvement with the existing precertification process Scorecards for productivity and QA were created to assist with this training as well as denial feedback. Leadership implemented a payer scheduling grid for diagnostic tests. Financial Clearance Policy was also implemented.

In-Scope Preauthorization Accounts Inpatient and Observation Surgery (Surgery, Heart, Gastro, Bariatric) Radiology – High Dollar PET Nuclear Medicine CT MRI Some ultrasounds Cardiology OTC Pain Management Interventional Radiology Sports Medicine

Preauthorization Responsibility Insurance Verification Preauthorization Clearance Patient Responsibility Estimation Medicare Medical Necessity Checks Price Line Coverage Missing Insurance Reports ED High Dollar Services Paper Vision – Order Indexing

Patient Access Current State Patient Access Points of Entry 2 Centralized Hospital Registration Departments 2 Emergency Departments 1 Women’s Center (L&D) 6 Outpatient Centers Non-Patient Access Points of Entry 3 Rehab Centers 8 Outpatient Centers

Patient Access Using initial rejection reporting and backend denial reporting, PAS has identified: A breakdown in existing process on the eligibility return Provide ongoing feedback and training to associates Strengthen their registration process as whole

PAS Point of Service Collections

Coordinated Care Identified trends associated with authorization denials during the utilization review process Patient type problems Medical necessity issues Length of stay issues Created the “No Authorization Discharge” report for Coordinated Care.

HIM (Health Information Management) HIM discovered new trends associated with coding and/or physician documentation deficiencies. The team was able to: Direct feedback to physician and clinical staff regarding the over use of hydration charges. Identify coding errors based on LCD & NCD guidelines. Provide additional training and feedback to coding auditors.

Revenue Integrity Revenue Integrity discovered trends associated with charging and payer issues. The team was able to: Provide direct feedback to charging departs regarding late charges. Pharmacy and Lab Identify policy changes to help patient account associates. Multiple scans done on the same day (Aetna Incidental Ultrasound Policy) Charging of implants (revenue codes for “inside or outside” the body) Identify charging issues related to high cost drugs (REMICADE)

Patient Accounts Patient Accounts discovered payer trends associated with medical records requests and non-covered services. The team was able to monitor these payer trends and escalate common payer issues. Modified process of submitting medical records Express priority mail CD format Limited vs. entire record Provided education to associates on experimental related denials. Implemented Amniofix process Monitoring 3D Imaging usage and reimbursement

Patient Accounts Denial & Appeals Success Rates Dollar recovery (Success Rate) has been steadily improving since initiation of SWAT

Write Offs Comparison FY2016-2017 As a result of our efforts, GHS had a write-off reduction of 40.6% from FY2016 to FY2017

Write Offs Comparison FY2017-2018 As a result of our continued efforts, GHS had an additional write-off reduction of 9.8% from FY2017 to FY2018.

Questions?