Payer strategies and the long road to payment

The average cost of debunking a denial is $25 per claim, not to mention the ongoing challenges associated with obtaining timely payment. Regularly reviewing rejection management strategies can be a more efficient payment path.

Claim denials are an ongoing challenge for the healthcare industry as providers grapple with write-offs and the resources to manage them. Indeed, a well thought-out strategy will improve the financial performance of claims; however, as the causes of denial continue to evolve in complexity, the strategy for addressing denial must continually be evaluated and transformed in order to remain effective. To ensure the accuracy of payor payments, providers need a strategy that handles denials with a current and comprehensive approach.

Ongoing assessment to substantiate accurate claims, produce fewer denials, and help prevent manual retakes following denials is critical, and knowing where to focus improvements is essential. Artificial intelligence (AI) and system automation flags for denials can be effective; however, if there are policies missed on the payor’s side, such as time restrictions, updates to the payor’s policy manual that do not coincide with an organization’s negotiated care management contract render inefficient automation. All aspects, from data accuracy to payer requirements, need to be explored.

With a monthly deluge of claim denials, investigating the root causes of late payments or late payments leaves an organization exposed to ongoing denials that could be resolved. In an effort to stay on top of why a payor is denying a claim, identify organizational processes and disjoint educational needs. It is important to assess the source of uncovered services.

There are a myriad of reasons for an uncovered denial of service. A few of the most common are incorrect ICD-10 or CPT® codes, providing services that are not covered, and inaccurate or omitted information, which can occur early in the revenue cycle. Denial information is powerful for identifying organizational challenges and creating transformational change. Awareness related to the direct or indirect cost of a denial, service-specific feedback, and recommendations for improvement enable ongoing opportunities to identify, secure, and resolve recurring claim denials.

With the consolidation of many of the nation’s largest insurers, Pharmacy Benefit Managers (PBMs) and specialty pharmacies into health care conglomerates, many health insurance companies now require certain medications to be filled by a specialty pharmacy. third party. Because these are often intravenous (IV) medications that must be infused by a health care provider, inpatient infusion clinics and doctor’s offices must accept “white (or brown) pouch” medications. .

The “white bag” prohibits a supplier from ordering and managing the handling of a drug used in patient care. Instead, a third-party specialist pharmacy distributes the medicine and sends it to a hospital or doctor’s office on an ad hoc basis.

The “brown bag” is similar to the white bag; however, in this case, the third-party specialty pharmacy dispenses the drug directly to the patient, who then brings the drug to the hospital or doctor’s office for administration.

Providers are clearly impacted by “bagging” mandates from some payers, as in many cases providers are no longer able to seek reimbursement for these drugs. Some payers have suggested that hospital-based infusion centers or medical practices may still be able to seek reimbursement for administering these drugs. Often, providers are informed of the implementation of these policies by the payer with little or no notice. Specific language prohibiting this practice may be used when negotiating the payer contract.

Alignment between payer and provider is absolutely necessary to promote the quality of the overall patient experience. Payer scorecards, managed by an organization, will facilitate cooperation between payers and providers. Tracking the range of payer patterns and measuring metrics such as reason for decline, average time to pay, payer first response rate, and decline cancellation rate can help providers better adapt improvements and to determine the root causes. This allows providers to obtain the necessary information related to payer prioritization. This information may also prove useful when negotiating or renegotiating a managed care contract.

As healthcare providers know, these metrics vary widely from payer to payer, and understanding the details will provide tools to improve processes. Creating these “payer scorecards” will help prevent denial and minimize manual rework.

Deploying a denial prevention targeting process centered on current trends will have a significant impact on prevention. A successful RCM must move to more concrete and targeted prevention in order to effectively reduce refusals. In short, preventing denial requires a new strategy.

Note on programming: Listen to Susan Gatehouse live today when she co-hosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.


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Elaine R. Knight