Challenge

When insurers and other payers decline to cover patient costs for medical treatments the denials can severely impact financial performance.

Many healthcare organizations resign themselves to writing off losses—potentially millions of dollars annually—due to inexperienced resources, unfamiliarity with payer-specific criteria and lack of standard processes. Additional reasons for not appealing include ineffective clinical documentation, inappropriate management of the level of patient care and reactive/delayed practices for communicating with payers.

A large US healthcare organization sought help from Accenture to pursue three goals:

  1. One-time recovery of millions of dollars in backlogged cases
  2. Establishing better practices for the prevention of denials and appealing denials
  3. More robust/proactive tracking and reporting of denial root causes

Accenture and the client worked together to exceed the initial recovery goal of $2.1 million by a large margin. In roughly six months, the project team recouped more than three times the initial goal: $6.7 million.

Strategy and Solution

  1. ONE-TIME RECOVERY.
    Accenture immediately set out to reduce the load of open accounts and to recoup funds, focusing first on clinical denials exceeding $5,000. To succeed, team members first needed a thorough understanding of the requirements established by the region’s major insurers and payers. Members of the project team reviewed the cases, and called payer organizations to clarify reasons for denials and terms for payment.
  2. LONG-TERM IMPROVEMENT STRATEGY.
    By examining hundreds of cases and tracking trends, Accenture identified root causes for clinical denials. At the front end, Accenture advised staff on making better use of clinical decision-support software, completing reviews in a timelier manner, strengthening Electronic Health Records documentation (EHR), proactively managing the patient’s level of care and length of stay, and leveraging technology to enable automated processes, real-time tracking and reporting.
"Our mindset is ‘everything is appealable’, rather than looking for only the low-hanging fruit, we harvest the whole tree."

– DAVID BALDERSON, Senior Manager, Accenture Health

Recouping losses

This Provider sought help from Accenture to establish a baseline of recouping funds from outstanding clinical denials.

Client profile

This Health Provider operates several hospitals, nearly 20 urgent-care centers and almost 100 physician practices in the southern United States.

Opportunity

Rather than writing off millions of dollars in denials due to a lack of resources and expertise, the Provider wanted a new, more aggressive approach.

Solution

Accenture outlined a two-pronged approach: Recovering millions of dollars in cases since October 2015 and establishing better practices for appeals.

Transformation

The gains topped the $7 million mark as of May 1, 2017 and the scope of the initiative continued to expand due to the recent acquisition of another facility with a backlog of denials.

In addition to the clinical denials program, Accenture is working with the client on multiple fronts to transform care management. Accenture is assisting with assessments made in emergency departments, suggesting ways to reduce excess days in care, streamlining discharge procedures, and centralizing functions and processes across facilities in the expanding healthcare network.

Positive results

The project team greatly exceeded the initial target of $2.1 million in roughly six months.

$2.1M

Amount recovered in 1 month

3X

The client was able to recover more than 3X the initial goal

$6.7M

Amount recovered in 6 months

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