Thinking back to playing tug-of-war on campus brings back that feeling of struggle and exhaustion. Despite all your efforts, it seems that you can’t make up much ground. Even the ropes will start to feel like part of the fight.
During the pandemic, the push and pull of payer denials of claims has left many providers feeling equally exhausted. Unfortunately, from a revenue cycle perspective, this is just the beginning. Payers are still catching up with 2020 denials due to Covid-19, CMS continues to change regulations, and the evolving value-based care paradigm is adding new complexities. All the while, suppliers are short on resources and need to put every penny out.
As rejections continue to change rapidly, suppliers will benefit from transforming the retrospective process into a continuous prevention process across the organization. The transition doesn’t need to be expensive or complicated. It just has to focus on root-cause remedies for rejections that will allow providers to stay ahead of payers that have traditionally prevailed. Since the onus is on the provider to bear the burden of proof, here are some suggestions for stocking up on denial prevention kits to stay ahead of the curve.
Investigate the audit environment
Even before the pandemic, the field of auditing had changed. Providers are seeing a shift in focus from rejecting diagnosis-related groups (DRGs) to rejecting clinical validation (CVD), a more subjective approach, leading to a dramatic increase.
The Covid-19 pandemic has wreaked havoc on the revenue cycle, exposing gaps that supplier organizations have been turning a blind eye to for years. In 2020, payers gave a pass on various claims and kept changing the associated dates for code changes, creating more confusion. Vendors already lagging behind have fewer and fewer resources to address increased denials as the pandemic presents staffing challenges. Most suppliers have no reserves.
Physicians have also undergone dramatic changes through the Evaluation and Management (E&M) code, which further complicates the environment. The rules have become more vague, leading suppliers to simply cancel rejections that require too much rework. Rejection is more of an afterthought about the supplier’s workflow – the hassle that will be exposed at the end of the revenue cycle. Unfortunately, as these factors have intensified in recent years, most vendors are just trying to stay awake.
Even if the provider submits a clean claim, the payer can deny them. Even payers have proven difficult to keep up with changing codes, sometimes responding immediately with denials.
Again, the burden of proof is on the provider who has to send detailed records and go through the process, even though they may have done their due diligence. It’s important to note this trend, as providers often tend to ignore rejections because they think they’re doing the “wrong” thing. Rather than worrying about the issue, provide better service to suppliers, proactively address denials, and develop an organization-wide strategy for those pain points that need to be alleviated.
stock kit
Even in the current chaos, suppliers have an opportunity. As providers seek to successfully navigate this complex and rapidly changing environment of rejection, the use of the following tools as part of a forward-looking approach (rather than a retrospective one) will be critical:
- Invest in coding team training and education. Accurate coding is the basis for obtaining arrears. Addressing errors early in the revenue cycle provides the supplier with the greatest opportunity for optimal compensation.
- Ensuring physician involvement in maintaining complete clinical documentation. This will allow you to push proactive denial prevention further upstream. Return to the office regardless of where the patient is in the care process; the form should be filled with correct information in a timely manner and include a grading condition category (HCC) code. From a risk-adjusted perspective, accurate physician coding is integral to success.
- Implement an Outpatient Clinical Document Integrity (CDI) program. Use it to facilitate accurate representation of clinical states. Among those who have surgery, there are many organizations that have not yet started out on an outpatient basis. This is a mistake; it has great value.
- Emphasis on patient experience. As a provider, it is important to pay attention to the bills that patients receive. Wacky copays or inaccurate charges are unfair and have little effect. Patient satisfaction and quality are important, and of course accuracy is also important.
- Find the biggest pain pointsIdentifying the most problematic specialties or areas in an organization is critical when vendors say they cannot keep up with changing rules, or they often feel overwhelmed by rejections. Where are the most lost dollars? From finding the income, the small pieces of the puzzle are put together.
By adopting these tools across the organization, providers can prepare for audits that may occur at any time. Regardless of the payer’s actions, suppliers will be prepared to respond appropriately due to the focus on the entire revenue cycle and its contributors.
Additionally, the supplier must have a realistic strategy. Remember, in a tug-of-war, power consumption alone is not enough to win. The strategic, thoughtful, coordinated movement of teamwork does exactly that. Providers must use the same strategy.
By engaging various stakeholders and departments across the organization, providers can achieve a Clinical Integrated Revenue Cycle (CIRC) that provides a holistic view of the patient care process. Clinical assessments and financial considerations no longer work in isolation, but work together to achieve common goals. This translates not only to healthier revenue cycle management, but also to value-based quality care – the future of healthcare.
Photo: designer491, Getty Images
