Providers, nurses, clinical care specialists, health information management (HIM) and utilization review professionals, clinical coders, and clinical documentation integrity specialists (CDISs) are all key to ensuring the integrity of coding, which is an essential requirement in denials mitigation. Collaboration is the theme of my presentation at the American Academy of Professional Coding (AAPC) HealthCon 17 this week in Las Vegas (http://www.healthcon.com/session-information.php).
Titled “Benefits Realization from Collaboration: Embracing and Integrating the focus on Clinical Documentation Integrity,” the presentation explores a concept that I believe is a critical success factor for effective revenue cycle governance.
Over the last few years, many organizations have encouraged collaboration among the revenue cycle team, CDI, case management, utilization management (UM),and coding staffs. Each of these lines of business was challenged with its own unique goals, yet they also shared the mutual goals to lower length of stay, to ensure accurate coding substantiated in the clinical documentation, and to practice appropriate handoffs of proper notification and authorizations. Working together and sharpening their skills significantly improved workflow, yet it did not address all the denials coming into the organization due to lack of authorization, medical necessity, and/or inaccurate or incomplete coding.
As believers that well-thought-out front-end design eliminates re-work, the realization became clear that the only real solution to managing denials was to deploy a denial mitigation strategy. This meant moving many critical steps upstream in the revenue cycle workflow. The greatest opportunity for collaboration between HIM, coding, case management/UM, CDI, and the revenue cycle teams was found in the task of deploying a workflow redesign with a new pre-bill review process. Long gone are the days of releasing a claim as fast as possible, without regard to the CDI or lack thereof, impacting future denials.
Core CDI is a requirement for a strong denial mitigation program. Creating a denial prevention program requires collaboration and an understanding that we are all on the same team, operating with the same unified goals. The entire intent is to prevent the denials from happening in the first place. This is done by deploying a pre-bill review process of the clinical documentation, associated coding, and claims data content.
According to one recent report, the average rate of claims denials in U.S. hospitals ranges from a high of 10.58 percent in large hospitals (250-400 beds) to a low of 5.61 percent (100-250 beds) , with averages for very large to medium-sized hospitals in the areas across the nation tending to fall predominately between 7 to 9 percent.
A pre-bill review process essentially is the denials mitigation unit. Deploying a manual pre-bill review process is the best place to start, following an assessment to determine the types of discharges and encounters that should be routed for pre-bill review. While working on this effort, seek to embrace technology! Create workflow tools for routing the “right cases” and opportunities to create flags and edits in your existing electronic health records (EHRs) and clinical and financial systems.
Technology-enabled pre-bill CDI and coding review with a CDI and coding component, supported by an approved revenue cycle bill hold, will be critical as it pertains to decreasing the denials received in your organization.
Action items for you to consider the following:
- Conduct an assessment of the current reasons for your denials and evaluate what could have been done pre-bill to avoid the situation.
- Identify the types of cases to include in the pre-bill review process, for example:
- High-dollar inpatient claims
- Low-dollar outpatient claims
- Targeted DRGs
- Opportunities for missed CCs/MCCs
- Physicians with high-risk cases/poor documentation
- Medical necessity risks identified in your assessment
- Evaluate workflow redesign options in your existing technology (EHRs/revenue cycle) to flag cases for review.
- Identify the skills required for success and evaluate the teams within your organization; identify any gaps in the skill sets needed for your pre-bill denials program.
Creativity in front-end design is one way to identify and catch many of these and other issues, as well as a pre-bill clinical documentation and coding assessment and the creation of a dedicated team to work your pre-bill denials avoidance initiative. It is time to be thinking denial avoidance; long gone are the days of managing these questions on a retrospective basis.
