Stop the Snowball: Adopting a Proactive Approach to Denials

A Conversation with Tara Dwyer, VP of Audit Operations at Xsolis

What does the current compliance landscape look like?

With ever-changing regulations, payer requirements, self-denials, and process errors chipping away at their claims, providers feel the financial pinch as denials accumulate. I’ve seen numerous organizations’ bottom lines shrivel because of denied claims, which often appear to have a snowball effect – one claim turns into another which turns into many, especially if the root causes of these denials aren’t identified and addressed.

What can providers do to stop denials beforehand?

Reframing revenue defense is possible, though not easy. The first step is bridging the silos between decision-making that leads to denied claims and the ultimate outcome of the claim itself. Without oversight and insight, finance leaders are forced to take a reactive approach, trying to stop the flow of dollars out the door instead of ensuring that those dollars stay put in the first place.

New technology, including advanced analytics, bridges these gaps. Analytics connect concurrent decisions to predicted outcomes, helping nurses and clinicians make the determinations correctly up front. Technology platforms also provide insights into each case as it progresses throughout the care and claims continuum, opening a new level of visibility into what went right or wrong along the way.

And for claims that are still denied?

I’m all too aware that as a part of the arbitrary nature of the denial and appeal environment in which hospitals operate, some cases will be denied regardless of proactive avoidance efforts. Dealing with these denials is an art form unto itself. An effective denials management process requires working the right cases at the right time by the right people with the right data. An important aspect of this is taking a strategic approach to appeals: technology now allows for the scoring, stratification and prioritization of cases by likelihood of success, which can mean more dollars more quickly.

Diligent follow-up is also crucial: payers do their best to ensure those denials stick, but with the right approach and the right data in your corner, the review turns in your favor. As no two cases (or corresponding appeal letters) are the same, you must often employ a unique and creative approach. Whenever applicable, reference and utilize clinical indicators and evidence-based medicine, along with current regulatory guidelines. Pay close attention to Medicare and Medicaid rules and regulations, and other payer-specific contract terms. I’ve seen providers build upon their success at overturning denied commercial claims through alternative avenues, including engaging the state and filing provider complaints where the appeal was not reviewed adequately or was denied inappropriately.

Most importantly, find the partner, personnel or processes that give you a fighting chance and put the odds back in your corner.  Denials can be mitigated and managed, but only through a diligent, proactive approach backed by technology.


About Tara:

Tara joined the XSOLIS team in August 2013, and serves as Vice President of Audit Operations, a position responsible for all commercial and government denials/appeals as well as quality validation for the clinical data. Tara has over 30 years’ experience working in the financial and revenue side of healthcare specifically working with denials, coding and billing best practices, performed commercial insurance audits on both the hospital and payer side. Tara received her Clinical Documentation Improvement training through 3M Health Information Systems and is an active member of ACDIS. She received her RN from Broward College School of Nursing.