High impact ways to defuse health claim denials
November 11, 2019
Denials represent the biggest area of strife for many hospitals. They stifle revenues and drive huge amounts of provider, patient and customer dissatisfaction.
For many hospitals and health systems that use electronic medical report (EMR) systems, the sources of denials include high-risk diagnoses, arbitrary payer determinations, physicians who don’t provide clinical support and coding errors. The root cause of many of these denials typically boils down to coders who lack the clinical experience to determine the correct codes and diagnosis-related groups (DRGs) on a claim.
One solution to the industry’s current denial deluge involves setting up multi-disciplinary CDI teams of clinical professionals and pairing them with Health Information Management (HIM)/Coding professionals utilizing third-party CDI tools. This approach can enable the timely and accurate review of charts and ultimately prevent denials. Using third-party CDI tools and/or launching an operational CDI process that hospitals can use in their existing EMR can improve follow-up with providers, giving an accurate review of clinical documentation and ultimately preventing denials on an upfront basis. Coders can then accurately code an account in the EMR and assign the appropriate billing DRG on the claim. This approach has a strong track record. According to a 2016 Black Book Market Research Report, nearly 90 percent of the hospitals with more than 150 beds that used CDI tools saw increases in their revenues and claims reimbursement of at least $1.5 million.
Other ways to prevent denials and add value include making improvements in operational processes or within the existing EMR. CDI specialists are doing more to prevent denials by reviewing Complication or Comorbidity (CCs) and Major Complication or Comorbidity (MCC) to protect cases and focusing on high-risk DRGs and diagnoses. Likewise, making user-friendly improvements to the EMR, including improved workflows, new work queues that flag accounts for CDI review and the use of documentation templates, can also help prevent denials. As an added benefit, streamlining operational processes and building multi-disciplinary CDI teams should produce increased revenues. Using artificial intelligence (AI) or natural language processing in a CDI tool can effectively streamline the ability of CDI specialists to focus on more complex diagnoses, such as sepsis. In addition, companies can use robotic process automation (RPA) to reduce clicks in the third-party tool, streamline the documentation review process and optimize provider follow-up for RNs. It can also enhance the interaction of the third-party tool with the EMR system.
Bottomline: Hospitals with EMR systems should considering implementing a CDI program (with both clinical and HIM/Coding professionals), using CDI tools to help prevent denials, increase revenues and boost claims reimbursement.