Surviving Denial Management…

Sharon Easterling, MHA, RHIA, CCS, CDIP, CRC, FAHIMA
Member, ACPA Advisory Board

Denial management can be an exhausting job. This is even more true when you are the lone denial coordinator managing the entire process of identifying or receiving a denial letter, performing data entry, responding to the denial from initial response through all levels of the appeals process, monitoring status, and following up. Of course, that does not include receiving and logging the determinations that can be joyous or quite frankly…the pits. Yes, especially when you just knew that was a good letter you wrote. Staff turnover in denial management can be real. The payers and contractors are always looking through a different lens. The success may not come often and there can be a feeling of defeat. New staff in denials are coming on board every day and providing insight and knowledge is a continuous cycle; never ending frankly. Keep your head up! There is hope to help retain your staff, reduce turnover, and alleviate employee dread. The following are best practices that can lead to success:   

• Hire the right staff: Your vision for the job will dictate the perfect candidate. If your vision is just level of care response and support from coding for coding issues, you may want a nurse with care management (CM)/utilization review (UR) experience. If your vision is the coordinator responding to coding and billing with support from CM/UR, you may want an experienced coder with IP and OP experience. This can be done inhouse, but outsourcing this process in some way may be the answer for you. Know your volumes, what you are seeing, and this will lead to the best approach. 
• Physician support: This support is invaluable and can help you with level of care, clinical validation, and DRG denials. Ensure there is a physician available to support the coordinator and the appeal process. It can make the difference between a denial being upheld or overturned. This is also key to successful peer-to-peer discussions with payers and contractors. 
• Staff training: Denials come in many formats and a multitude of types. Make sure your coordinator understands the type of denial received and how to address it. This may involve some on-the-job training but there are resources out there to gain a good foundation. This will be helpful if your process is hybrid with external vendors or all internal and aligned with key departmental staff to reach out to for assistance. 
• Get organized: Not being organized can be the difference between a good day and dollars lost. Keep denials in a format that detail is easy retrieved and can be easily tracked. Folders can be maintained alphanumerically for provide easy access or numerically. Decide what works best for you. 
• Spreadsheets vs Software: When there are no other options due to budget constraints, spreadsheets are an answer. Keep in mind you can link spreadsheets now and use Power BI to connect data and visualize. If at all possible, eliminate spreadsheets and obtain software to help manage the process. This provides all information in a click and can be ideal for reporting. When you can budget and obtain software, you can centralize your process and bring in other users with different levels of access and responsibilities. There are many types of software and prices vary. Do your homework and due diligence to find the right product for your organization. I have talked with many providers that have made a bad choice and had to reinvest or be stuck with an inadequate product. 
• Stay connected: Staying abreast of the latest and the greatest news is vital in denials. What are your MACs doing, what is happening with recovery contractors, what is the OIG up to, how are others handing Medicare Advantage, etc. These are a few areas that are important to monitor the pulse of. Follow and signup for email alerts from payers, CMS, contractors, and groups/associations to stay ahead of the game. Key links below: 

• CMS Listserv signup 
• OIG alerts 
• CMS Contacts Database 
• CMS Functional Contractors 
• CMS MACs 

• Support staff: Regardless of how you maintain data, support staff is crucial. The coordinator can not do it alone. Of course, volume plays a role in this decision. These days a 400-bed facility can receive around 10-40 denials per week. These come in the form of letters and via the billing system. Investigate how the coordinator can get support for data entry and reporting. It is unrealistic to think you can respond well and get good data without adequate tracking. 
• Celebrate the wins: Everyone likes to feel appreciated and know they are valued. Highlight the success of your team. They have your back and may be warding off potential undue scrutiny. 

Don’t let your denial coordinator burn out. Put tools in place to assist them and set them up to be successful. Remember, ineffective Denial Management is like opening a window and throwing out dollars. Keep your windows closed and keep the revenue you deserve in. 

Sharon is the CEO and founder of Upskillz and creator of the HCCWise, CDIWise, and E&MWise Apps and Strategic Client Executive with eCatalyst