1. 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

2. TEAM “D”
Transforming
Expert
Analytics
Managing
Denials

3. Denials can cause havoc on your A/R.

4. 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. 

5. 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

6. 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

7. 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

8. Denial Categories

9. Payer Mix

10. Denials by Area/Ownership

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

12. Insurance Scheduling Grid

13. 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.

14. 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

15. 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

16. 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

17. 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

18. PAS Point of Service Collections

19. 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.

20. 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.

21. 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)

22. 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

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

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

25. 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.

26. Questions?