Denial Management: Working Together to Identify the Cause

Shari Garceau, MSN, RN, CCM, CMAC, ACM-RN, TCM, CLSSGB

Angela Chisholm, MAHS, BA, RN, ACM-RN, CMAC

Denial management is an integral and crucial part of any organization's comprehensive risk management strategy. When denials occur, it is imperative to address them in a manner that fosters collaboration, encourages solution-oriented approaches, and avoids assigning blame. Emphasizing the importance of a collective effort to identify the root causes of denials without assigning blame to an individual department is vital for effective denial management. Most denials occur due to gaps in processes and communication between multiple departments. Working collaboratively with clearly defined roles and responsibilities is critical to denial management.

Recognizing that denials often originate from systemic issues rather than individual errors is essential. Therefore, the primary focus should be on comprehensively understanding the underlying causes of denials, implementing necessary organizational changes, and establishing preventive measures to avert future occurrences. Organizations can significantly mitigate the impact of denials by fostering a culture centered on openness, transparency, and active communication.

In dealing with denial management, creating a blame-free environment where all members of the revenue cycle feel empowered to share their findings and proposed solutions without the fear of reprisal is paramount. This approach paves the way for a more thorough exploration of denial patterns and facilitates the development of targeted and practical solutions.

Furthermore, promoting cross-departmental collaboration is crucial for successful denial management. Involving a wide array of stakeholders, including clinical staff, billing, and coding teams, as well as the Executive Leadership and insurance payor representation, not only allows organizations to benefit from diverse perspectives and insights but also makes each member feel valued and important, contributing to a comprehensive analysis of denial causes.

Leveraging data and analytics to identify trends and patterns related to denials holds significant value. By utilizing data-driven insights, organizations can identify recurring issues and proactively address them, thereby minimizing denials and improving overall operational efficiency. This approach not only keeps your team informed but also empowers them to make data-driven decisions.

Ultimately, the overarching objective of denial management should be to establish a unified and proactive approach to addressing denials. Organizations can transition from assigning blame to implementing sustainable solutions that drive continuous improvement, emphasizing the core values of collaboration, transparency, and data-driven decision-making. Working collectively to identify root causes without resorting to blame leads to a more agile, effective, and resilient healthcare environment.

Both Shari Garceau and Angela Chisholm are Managing Consultants for Guidehouse, LLC based out of Austin TX and Houston TX respectively.