Q&A: Implementing processes for denials management

Q: What processes or systems do you have in place for managing denials?
Maureen Sloane, RHIT, COC, chargemaster manager at Northside Hospital in Atlanta, Georgia: Our denials management department is ultimately responsible, but they certainly reach out to us in revenue integrity and ask for assistance. A lot of times they ask us why payers are denying certain claims and want to know more about the type of issue they’re dealing with (e.g., charge, coding).
Tina Bui, reimbursement integrity manager at Children’s Hospital Colorado in Aurora, Colorado: At Children’s Hospital, when we receive a denial, a follow-up record is created in Epic automatically and sent to the designated revenue cycle department that owns that denial reason. Each revenue cycle area is responsible for the initial review. If the denial requires an appeal, the team can route the account back to the billing office since they have a dedicated denials team to coordinate the appeals process to write the letters and follow up with the payer. If we identify a trend or pattern, it is escalated to a weekly joint call we have our billing office to validate the root cause and develop an action plan to prevent future denials. Most recently, Children’s developed a multidisciplinary review of top denials that happens monthly.

Editor’s note: This article was excerpted from the 2023 State of the Revenue Integrity Industry Survey Report. Read the full report here.