2019 ACMA National Poster: Building a Successful Denial Management and Revenue Recovery Strategy

C ONCLUSION Building an organized denials and appeals process fosters a culture of accountability and transparency that improves interdisciplinary communication and collaboration. The process protects important revenue for any hospital. Real time data collection and reporting is a key factor in evaluating and monitoring the success of the denials management program. A strong physician advisor is an important component to the success of the peer to peer process.

Care Management Departments are the most knowledgeable resource for the mitigation of denials and managing the concurrent denials and the appeals process at all levels.

A BOUT S TAMFORD H EALTH Stamford Health is a non-profit independent healthcare system with more than 3,500 employees committed to compassionately caring for the community and offering a wide-range of high-quality health and wellness services. Patients and their families can rely on comprehensive person-centered care through the system’s 305-bed Stamford Hospital; Stamford Health Medical Group, with more than 30 offices in lower Fairfield County offering primary and specialty care; a growing number of ambulatory locations across the region; and support through the Stamford Hospital Foundation. Stamford Health is also a major teaching affiliate of the Columbia University College of Ž Physicians and Surgeons and is Magnet Designated.

The Care Management Department is comprised of RN Clinical Case Managers, Social Workers, Clinical Documentation Specialists and Clinical Appeals and Denials Strategists and Case Management Assistants. The Care Management Department is supported by a Manager of Social Work, Manager of Case Management, an RN Care Management Director and a Medical Director/Physician Advisor.

Building a Successful Denials Management and Revenue Recovery Strategy

AUTHORS M ARY L AUCKS , RN BSN MSHA CCM D IRECTOR C ARE M ANAGEMENT D EPARTMENT MLAUCKS @ STAMHEALTH . ORG G EMINA M. F ADIL , RN BSN CCDS C LINICAL D ENIALS & A PPEALS S TRATEGIST GFADIL @ STAMHEALTH . ORG O NE H OSPITAL P LAZA , PO B OX 9317 S TAMFORD , CT 06904 P HONE : 203.276.1000 StamfordHealth.org

M ARITA C. P ERALTA , RN BSN CCM C LINICAL D ENIALS & A PPEALS S TRATEGIST MPERALTA @ STAMHEALTH . ORG

BACKGROUND Hospitals nationally struggle with claims denials and concurrent clinical payer denials. These denials delay the overall time to reimbursement and impact the bottom line and net revenue. “The advisory board’s biennial revenue cycle survey finds that a median 350 bed hospital would have lost $3.5 million to increased denial write-offs from healthcare payers over the last four years”.

(Macdonald, I. 2017, November 15 www.fiercehealthcare.com).

Fiscal Year 2017 and Fiscal Year 2018 showed a significant increase in medical necessity denials and write-offs for non-payment. The process for written appeals had been outsourced to a private company and the Care Management Department was not proactively mitigating clinical denials on a concurrent basis. In addition, there was not a department level report that would identify the type of denial or the volume of denials. All of these factors contributed to the breakdown of the denials management process which resulted in revenue loss and leakage.

M ETHODS AND S TRATEGIES Analysis and Management  

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identify key indicators for a denials management strategy

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develop a department level dashboard for denials, appeals and revenue recovery

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optimize the Physician Advisor role for positive Peer to Peer outcomes

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develop and train specific staff members for the role of Clinical Denials and Appeals Strategists

Education and Team Building   

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developed the staff assigned to the newly created role for denials and appeal assessed current table of organization in the Care Management Department engaged the Care Management Department staff and provided re-training on the UM process, denials and appeals established a department goal to reduce commercial medical necessity denials that reached the written appeals process by 10% for FY18 presented monthly denials and appeals data at Care Management Staff meetings

Process Improvement   

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LEARNING OBJECTIVES

performed a gap analysis on the concurrent clinical denials and appeals process assessed current table of organization in the Care Management Department for roles and responsibilities evaluated the denials and appeals being outsourced collected information by payer, reason for denial, date of denial, appeal due date, dollars at risk and total charges reviewed in detail monthly finance denial write off reports and identified trends

M ETHODS AND S TRATEGIES

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organized the workflow for concurrent and retrospective appeals optimized the current utilization management (UM) technology for tracking denials and appeals implemented bi-weekly meetings with the finance department to discuss high dollar inpatient cases and current denials and appeals optimized the Physician Advisor role for peer to peer consults with payers to mitigate denials real time moved the management of the clinical appeals from an external resource to our internal Care Management experts implemented a process for billing and accepting payment for alternate level of care when appropriate established a tracking method for data related to concurrent appeals, peer to peer results, re-bills and written appeals developed a workflow for the internal Care Management staff for real time notification of concurrent denials highlighting the importance of timely intervention developed a denials and appeals dashboard changed the practice model of Care Management from dyad to triad

R ESULTS 

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FY18 42% of denials were overturned ($1.08M), 25% ($639K) were upheld and 33% ($835K) are still pending determination the FY18 department goal was a 10% reduction in commercial appeals, that goal was surpassed at 65% maximized the Peer to Peer discussion capability with a success rate of 80% which equates to 3.8 million dollars in protected revenue from 3/2018-9/2018 in September 2017, 45% of denials were received from Finance and 55% were received by the Care Management Department. Currently, 97% of denials are mitigated directly via the Care Management Department which significantly impacts the time to reimbursement currently Q1 FY19 were are tracking at a 30% reduction in written appeals over FY18