Presbyterian Healthcare Services

Jerald M Archibeque

Healthcare denials are a significant challenge in the complex landscape of healthcare administration. Denials happen for various reasons, including administrative errors, lack of medical necessity, coding issues, eligibility and coordination of benefits issues, or incomplete documentation. Despite efforts to streamline processes and reduce denials, they persist at organizations nationwide, impacting providers and patients. Understanding the causes, consequences, and strategies for addressing healthcare denials is crucial for improving our patients' experience, as well as the efficiency and effectiveness of care delivery. Proactive identification and resolution of denial trends help identify root causes and prevent future denials. Collaborative efforts between healthcare providers, payers, and regulatory agencies are essential to streamline processes, reduce administrative burdens, and improve the overall efficiency and effectiveness of the healthcare system.

At Presbyterian Healthcare Services, a not-for-profit integrated healthcare system in New Mexico that includes nine hospitals, a health plan, and a medical group, we introduced denial information to clinical departments to share how workflow and processes—or lack thereof—can cause lost revenue. In 2016, this denial review started with our infusion department. The focus was on denial write-offs or denials in which the revenue is not collectible. This review created better awareness of how each spoke within the entire revenue cycle, including the clinical staff, contributed to the success of the organization. Over the next few years, we began to look at denial ‘inflows,' which are accounts that have not yet been lost. This approach led to a review of accounts that could still be saved, provided real-time feedback to staff, and helped overturn denials from insurers. This approach contributed to an overall reduction in denial write-offs for the department and contributed to an increase in the overturn rate to 90 percent of all denial inflows.

“Proactive identification and resolution of denial trends helps identify root causes and prevents future denials”

Accurate reporting is key, especially when revenue cycle team members are sharing information with clinical staff. We categorize the hundreds of claim reason codes used by payors into what we call ‘Owning Areas.’ This 10,000-foot look helps us determine the cause of the denial.

Owning areas include registration, provider enrollment, non-covered, coding, medical necessity, information requests, billing, and timely filing. We then drill down to patient-level detail to determine the root cause of the denial. We have begun to roll this approach out to departments across Presbyterian. In this process, it’s important to have representation from the entire revenue cycle team, including patient access, revenue integrity, coding, and patient accounting, to partner with clinical staff and identify areas of opportunity together.

Presbyterian has also begun looking at predictive denial analytics. In today’s landscape of insurance denials, it’s important to initiate work on these as soon as possible, and it has become necessary to ‘anticipate’ denials before the claim has even left the building. For years, we have had prebill edits built into our billing system and our clearinghouse. However, with predictive models built by our data and analytics team, we can now assign a percentage to an account with a higher chance of denial. This allows us to review prior to submission.

The consequences of healthcare denials extend beyond financial implications and impact patient care and satisfaction. Patients may experience frustration and dissatisfaction when faced with unexpected healthcare costs or barriers to necessary care. Furthermore, denials consume valuable time and resources, diverting attention from patient care. Addressing healthcare denials requires a multifaceted approach that encompasses proactive measures to prevent denials, efficient claims management processes, and effective denial management strategies. Healthcare organizations should implement robust documentation practices, provide ongoing training and education for staff on coding and billing guidelines, and leverage technology solutions that streamline processes and improve accuracy.

In conclusion, healthcare denials represent a complex challenge within the healthcare industry, driven by documentation errors, coding inaccuracies, medical necessity criteria, and administrative complexities. Addressing healthcare denials requires a coordinated effort to improve documentation practices, ensure coding accuracy, comply with medical necessity guidelines, and streamline claims management processes. By implementing proactive measures and leveraging technology and collaboration, healthcare organizations can mitigate denials, enhance revenue cycle management, and ultimately improve patient care and satisfaction.