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Navigating Denials Using the True Clinical Picture

Publish Date
Read Time
March 14, 2019

Now more than ever, the management of complex denials is paramount for organizations due to changes in payment methodologies, payer requirements, and patient consumerism. Navigating denials requires revenue cycle leaders to perform a “balancing act” that addresses both the management of complex, current denials, and prevention of reoccurring, systemic denials in the future. Health information management (HIM) professionals play an integral part in this balancing act through our role as ambassadors of the “True Clinical Picture.”

In a previous blog post, we noted that “When you focus on the True Clinical Picture, your organization can make meaningful use of health information and achieve positive outcomes for both your patients and your business.” In this post, we’ll focus on documentation and complex denials management resulting from a constantly changing landscape that contains many rules, regulations, and requirements enforced by payers, government agencies and even organizations themselves. And let’s not forget about the patients, who play a role in denials through the information that they provide.

The denials process is not new to the healthcare industry, yet many organizations continue to struggle with managing current denials, let alone taking the next step forward into denials prevention. A combination of factors contributes to this struggle:

  • Decreases in internal staff at the same time denials volume may be increasing
  • Multiple systems from which data must be extracted
  • Complex data that may lead to “data analysis paralysis”
  • A mixture of internal and external resources that may not be operating consistently

All these forces can lead to a vicious cycle that increases rework without ever solving the problem of revenue leakage. So, what can be done to ensure effective denials management?

Start with “Healthy Denials”

Denials happen. It’s what we do with the information gathered from denials that determines the future success of any denials management program. Are you aware of the healthy benefits of denials? Not only do denials challenge us and make us think about why they are occurring, but they are also the best tool for achieving prevention through education. Use denials to provide education on coding, documentation, and the importance of ensuring the True Clinical Picture is always captured.

Dig a Little Deeper for Complex Denial Management

The root cause of denials may seem straightforward when grouping large amounts of data. However, a closer look may reveal larger opportunities for improvement. Your “healthy denials” may reveal causes of denials that you are able to address through education. But when the items that typically contribute to denials are combined with other systemic challenges, your initial solution may not prevent denials and revenue leakage completely.

For example, the Master Patient Index (MPI) holds a wealth of information that supports the clinical picture of the patient, and a neglected MPI can be the foundation for many ongoing problems in the revenue cycle. Like MPI, other areas may singularly create problems for organizations, but when combined can create an increased denials rate that results in rework, lost productivity, and ultimately lost revenue. These include:

  • Complete orders to support requests
  • Creation of duplicate accounts
  • Documentation of symptoms and chronic conditions
  • Complete, concise, coding and billing
  • Documentation clarity and completeness
  • Multiple data sources without common data elements

To successfully address denials, it is crucial for clinicians and revenue cycle leaders to understand the elements that come together to provide the True Clinical Picture and for HIM professionals to lead efforts to ensure the accuracy and integrity of the data that will have a positive impact on potential denials activity.

Documentation as the Navigator

Complex Denials Management requires an in-depth understanding of the clinical documentation and supporting processes that accurately define and document the care of the patient. Navigating a course is easier said than done and becomes more difficult further upstream in the Revenue Cycle due to varied processes and interactions.

Clinical Documentation continues to become more and more complicated, driven by multiple data elements, systems, users, patients, and varied payer requirements all of which can lead to complex denials. HIM is uniquely positioned with a bird’s eye view of the revenue cycle that can help other parts of the organization successfully address complex denials.

Documentation is the ultimate navigator. Managing documentation and information from many sources internally and externally is a challenge for any organization. Understanding how to utilize documentation to navigate past, current, and future denials is the key. One approach or method will not serve as a long-term strategy in today’s healthcare landscape. A multi-faceted approach looking at denials through a different lens while utilizing quality documentation and the True Clinical Picture will pave a solid path forward.

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