As we delve deeper into the intricacies of denials management, understanding your denials team’s composition, structure, and collaboration efforts becomes paramount. There is no one-size-fits-all approach, and organizations should tailor their denials teams to align with their specific needs, resources, and historical success patterns.
The journey toward optimal denials management involves continuous refinement, collaboration, and strategic adaptation. Let’s explore key considerations to enhance the effectiveness of your denials team and streamline the escalation process.
Team Composition: PFS Representatives, Nurses, Coders, Billers, and Physician Advisors
The denials team is a collaborative effort, typically comprising PFS representatives, nurses, coders, billers, and increasingly, physician advisors. The inclusion of physician advisors has gained popularity as healthcare systems recognize the value of a higher-level clinical review. This interdisciplinary approach allows for a comprehensive assessment of claims, especially in scenarios where the clinical and coding perspectives might differ. The collective expertise facilitates a thorough examination of denial reasons and strengthens the overall team dynamic.
Collaboration: Operational Processes
Operational processes within the denials team can vary based on specialization and payer segmentation. Some teams focus exclusively on clinical or technical denials, while others manage a spectrum of audit types, including clinical validation, DRG, and charge audits. Payer segmentation may involve distinct teams for commercial payers, Medicare, and Medicaid. The flexibility in structuring your team allows customization based on your organization’s needs and resources.
Collaboration with all departments in the hospital during the negotiation of managed care agreements to ensure all costs are covered is often forgotten or not part of the operational process. When the contract is being negotiated, it really should be a collaborative effort across departments to make sure everything is covered at the necessary level to ensure:
- All costs are covered
- Realistic exceptions and conditions are incorporated to prevent denials
- Consistency in determining medical necessity through clinical review criteria stipulations
- Provider appeal rights are included (such as the use of Independent Review Organizations (IROs)
Payer Contracting: Internal Team Collaboration & Escalation
When it comes to managed care contracts and agreements, many providers incorporate a siloed approach with only the legal team managing the process. However, it is imperative all provider teams that play a role in the revenue cycle have a clear understanding of their managed care landscape.
Crafting appeals and disputes requires a collaborative effort utilizing supporting documentation and contractual arguments. And effective escalation efforts involve collaboration with both payers as well as provider internal teams. While maintaining a high level of clinical and procedural strength, teams may also include legal arguments when applicable. The goal is to present a compelling case for denial overturn, leveraging all available resources to build a robust argument.
Denials teams should engage with payers through joint operating committee (JOC) meetings or regular discussions. Collaborating externally with other hospital systems, either directly or through networking groups, provides valuable insights and shared experiences. Peer-to-peer reviews, internal appeal avenues, external appeal avenues, and even considerations for arbitration or litigation are aspects to explore based on the severity and persistence of denials. Additionally, payer relations play a crucial role in escalating denials. Strengthening payer-provider relationships fosters a collaborative environment where challenges are addressed collectively, leading to more efficient resolution of denials. Aggregating lists of accounts with trending denials and collaborating with provider relations can lead to more productive meetings.
Ready to begin your journey toward optimal denials management? Contact us today.