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

2. Documentation is key to Denial Prevention

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

13. 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

14. Trends in Clinical Denials:
DRG Reassignments

15. 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 , adult

16. 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.

17. 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

18. 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.

19. 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:

20. 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.

21. 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

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

23. 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

24. 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?

25. 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

26. 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

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