Creating an effective strategy to resolve Clinical and Coding Denials
As healthcare providers struggle with multiple headwinds, from rising labor shortages to declining reimbursements, they must recover the most from their revenue cycle. Claim denials, a chief cause of revenue loss to healthcare practices, are rising across payer types. A primary source of denials is on account of coding-related denials. A comprehensive and focused denial management and appeals strategy will help reduce this revenue loss. This article identifies the sources of revenue leakage on account of clinical and coding issues and proposes a comprehensive approach to plug them.
Reasons for revenue loss due to clinical and medical coding issues
The following are the main reasons for revenue loss due to clinical and medical coding issues in the revenue cycle
Discharges Not Fully Billed. Medical practices and hospitals lose 3-5% of their revenue due to DNFB issues. Due to the lack of knowledge of reimbursable procedures or tardiness in documenting all medical services provided, healthcare provider organizations leave revenue on the table. Expert medical coders who understand the medical specialty can help unearth these DNFB issues.
Coding Quality Issues. When medical coders incorrectly code a patient-physician encounter, it will lead to denials. Healthcare providers must invest in a coding audit function to perform quality checks and improve coding quality to avoid the recurrence of such denials.
Clinical Validation Denials. Medical codes that do not support the clinical services provided result in clinical validation denials. An effective appeals strategy for clinical validation denials requires better clinical documentation to validate clinical procedures and improved coordination between clinical documentation and coding personnel. With increased scrutiny for clinical documentation issues, a healthcare organization must provide compelling documentation as evidence, and the process often requires discussions with the physicians.
An approach to successfully appealing clinical and other denials
Denials management and prevention require effective collaboration across functional areas and ongoing discussions to eliminate the avoidable causes of denials. When denials do occur, medical practices and hospitals must follow a concerted and collaborative appeals strategy that includes the following:
Organizational Collaboration: Most denial management experts agree that ongoing analytics on the top reasons for denials is the first step in denial management and prevention. The collaboration between front-end, HIM & Coding, Back-end, Clinicians, and CDI teams will help uncover the root cause for each denial and pave the foundation for systemic elimination of the identified causes. Denials due to clinical coding quality and validation reasons require collaboration between the coders and physicians. Clinical Documentation Improvement (CDI) and coding teams must work with physicians to bring out clinical evidence to support the appeal strategy. A regular cadence of meetings between the coding and CDI staff can help improve the quality and specificity of coding.
Creating a cross-functional team for denial management – RCM personnel, CDI team members, clinicians, and technology teams must work together to bring up denials for a discussion. Each denied claim provides the learnings for the future, and a cross-functional team can work towards building systemic checks or just correct the actions that can trigger denials.
Templatize appeals. The denials management team must templatize appeals to obtain the right information from respective functions. Filing appeals promptly is essential to improve success rates. Healthcare organizations can consider outsourcing denials management and coding functions to improve clinical coding quality and the turnaround time required to file appeals.
Document success stories. Learn from successful appeals and document these as cases for reference. For Coding related denials, check the clinical validation and coding accuracy through additional references from AMA and AHA’s guidelines and tools.
Promote a learning culture. An effective denials management program has its anchoring in continuous learning. All stakeholders – front-end staff, clinicians, HIM, and coding personnel – must meet and collaborate to create organizational learning opportunities specific to the type of medical services provided.
Healthcare organizations can supplement their coding and denial management resources by adopting outsourcing as a strategy to address coding denials and accelerate the adoption of best practices for shifting focus from denial management to denial prevention.
Healthcare providers must train staff members on the insurance verification processes. Efficient processing reduces the likelihood of denials and accelerates the cash flow cycle.
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