Adam Gobin

Director, Revenue Management

Emory Healthcare

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

The Power of Hyper-specialization in Denial Management

Conflict of Interest Adam Gobin, MPH MBA

Has no real or apparent conflicts of interest to report.

© HIMSS 2015

Learning Objectives 1. Define denial categories by analyzing thousands of denial codes.

2. Apply management engineering techniques like DMAIC - to be able

to streamline denial management processes.

3. Design the simplest work flow for staff through hyper-specialization of

workflows, through denial centralization.

4. Diagnose the patterns of remit/claim denial codes – to foster both

predictive and prescriptive analytics.

5. Evaluate denial code mapping and categorization on a recurring

basis to ensure no interruption in workflow.

Value Step: Savings Financial/Business, Efficiency, Operational

http://www.himss.org/ValueSuite

30%

26%

45%

32%

Reduced

write-offs

Reduced

registration/

insurance denials

Reduced

Medical records

request denials

Increase in payments for

claims aged greater

than 180 days

Organizational Background

Emory Healthcare is the largest health care system in

Georgia and the only health network in the state that

brings together a full range of hospitals, clinics and local

practices

Emory University Hospital – #1 in Atlanta, #1 in Georgia,

Nationally Ranked in 5 Specialties, High Performer in 10

Specialties

Nearly 50% of Atlanta's Top Doctors are at Emory!

Emory Healthcare is the only health system in Georgia to

have hospitals ranked among the top 10 academic

health systems in America for quality and accountability.

University Healthsystem Consortium (UHC) ranked The

Emory Clinic in the top 5 for revenue cycle performance

4 years in a row

Administrative Simplification

“Physicians spend a reported 43 minutes per day on average—the

equivalent of three hours per week and nearly three weeks per

year—on interactions with health plans and not on patient care.” ~The Healthcare Imperative: Lowering Costs and Improving Outcomes

“Approximately $332 billion in administrative costs could be saved

over 10 years from simplification efforts." ~The Healthcare Imperative: Lowering Costs and Improving Outcomes

Two Fundamental Drivers for Success

Focus Design

“Healthcare expenditures are projected to be approximately $4.6 trillion or

20 percent of GDP by 2017. No other comparably sized, industry segment in

the U.S. has such weak administrative standards, adoption of existing

standards and disjointed, legacy operating platforms.” ~Fidelity National Information Services Inc.

Emory’s

Response:

2015 Forecast: Increased denials and Delayed Payments

Challenge Observation Impact

Insurance

Exchanges

1. Difficult to identify insurance

exchange members

2. Insurance companies are

sharing resources to connect

with insurance exchange

members

1. Self Pay: Difficult to collect

upfront

2. A/R: Processing claims is

delayed since insurance

exchange members are priority

for insurers

Increased

Medicare

Advantage

Business

1. Medicare Advantage plans

continue to attract

Medicare eligible patients

with greater coverage than

Medicare Part B

2. Large risk of Medicare

Advantage cuts in late 2014-

Early 2015

1. A/R: Medicare Advantage

plans take longer to pay with

the same reimbursement as

traditional Medicare

2. Payment Variance: Providers

are at risk for lowered

reimbursement

2015 Forecast: Increased denials and Delayed Payments

Challenge Observation Impact

Varying ACA

Interpretation

1. Insurance companies

have different

interpretations of the

ACA Preventive

Services coverage – a

loophole in the act.

1. A/R & Self Pay: Insurers have several

plans and each plan may have several

employer specific benefits – and at each

level, coverage can vary – thus

increasing non-covered denials and

administrative burdens to follow up.

ICD-10

Specificity

1. Insurers turned on ICD-

10 edits in 2014 to

prepare for the original

ICD-10 go-live date:

October 2014

1. A/R: Increased coding denials related to

specificity – insurers are asking for medical

documentation to specify regions for

Radiology scans for example. Whenever

an ICD code is unspecified or not

otherwise specified – physicians have to

show medical records.

Denial Management Complexity

Denial

Management

Phone

Calls to

Payers

Web

Portals Patients

Provider

Offices

Enrollment

Phone

Calls to

Payers

Records

Denial Centralization Pitch to the Team

Emory’s AR 2.0 – Denial Centralization

Denial Centralization: An asserted effort to centralize and standardize the AR workflow of denial management, discover root causes across all denial groups, & engage major stakeholders (vendors, payors or providers) to increase efficiency.

THE IDEA Payors & Providers work together for mutual benefits!

Define Denial Codes and Remark Codes.

Measure through daily and weekly pulse reports.

Analyze through concise project charter.

Improve through standard operating procedures.

Control through quality audits and monitoring “Days to Pay”.

Committee on Operating Rules for Information Exchange: Emory’s Integration

• Business Scenarios: – Scenario #1: Additional Information Required-

Missing/Invalid/Incomplete Documentation.

– Scenario #2: Missing/Invalid/Incomplete Data from Submitted Claim.

– Scenario #3: Billed Service Not Covered by Health Plan.

– Scenario #4: Benefit for Billed Service Not Separately Payable.

Categorizing claim adjustment reason codes (CARCs) and remittance advice

remark codes (RARCs) by groups – using CORE combinations – increases

efficiency of denial follow up and cash turnaround.

Define Denial Codes & Remark Codes

Reject Code Reject Reason Category

252 Missing Attachment Medical

Documentation

Phone calls to payers

Web portal claims status

Washington Publishing Company’s Data

Denial Categorization

Measure through pulse reports

Weekly/Monthly Tracking Leads to Key Actionable

Trends and more importantly – Payer/Provider Partnerships

$0.00

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

$3,000,000.00

$3,500,000.00

$4,000,000.00

DUPLICATE INFORMATIONNEEDED TOPROCESS

NON COVERED PRECERTREFERRAL

PROVIDERRELATED

REG INSRELATED

Oct

Nov

Dec

Both a weekly

& monthly

report

Emory’s Partnership with its Payers Led to Significant Process Improvements

Analyze through concise project charters & other PM Tools

Problem

Statement

Identified

Stakeholders

Mapped Current

State

Created Milestones

Measured Results

Transcatheter Aortic Valve Replacement (TAVR Case Study)

Results: 85% decrease in days to pay for TAVR claims

Improve through standard operating procedures

Bundling Denials

Results: 35% decrease in days to pay for bundling related claims

Control through quality audits

Twitter Approach to Text

Data or categorical variables

Instagram Approach to

Numerical data

Qualitative Audits Quantitative Audits

• Identify the frequent outcomes chosen

by the AR follow up team and strive for

automation or process improvement

opportunities

• Track quick stats on a weekly basis to

effectively communicate trends and

identify opportunities to streamline

Communication of Denial Trends/SOPs

• Emory created an Accounts Receivables Wiki page so that

communication of trends and findings (denial spikes, payment

trends, ) is real-time for all stakeholders across the organization.

Entry Date: 01/10/2015

Author: Adam Gobin

Subject: Incorrect Medicaid Denial (N55 Remark Code)

Impact: $2M – across all clinic specialties

Expected Resolution Date: 01/31/2015

Comments: Medicaid incorrectly denied claims with the

N55 remark code. Emory has re-filed all impacted claims

and expect to receive payments by month’s end.

Example Wiki Update

Future of Claims and Remits Analytics

Lessons Learned

• CORE Code Combinations = the Denial Centralization concept is born!

– Improving denial management through data analytics and management

engineering techniques.

– Working together to build a foundation for the future!

– 1st attempt for payors & providers working together for mutual benefit

(decreasing overall administrative costs)!

• General Implementation Considerations & Challenges:

– Planning and Resources reject code & type dictionaries.

– Implementation Considerations/Steps identifying centralized denial

groups, creating centralized denial teams & members, SOP’s & reporting

(stage summary, days to pay, etc.)

– Challenges & Resolution – stakeholder buy in, setting up systematic

accountability, generalists v. specialists, equivalent reporting.

Value Step: Savings Financial/Business, Efficiency, Operational

• The Emory Clinic leverages a relationship with CAQH – utilizing CORE code combinations to effectively redefine & centralize denial groups on a recurring basis.

• The Emory Clinic continues ongoing collaborations with payors,

clearinghouses, & banks to streamline workflows. • Breeding consistency, transparency, & accountability - denial centralization

has successfully reduced The Emory Clinic’s AR metrics:

– 7-Day Decrease in Total DAR!

– 25.6% Decrease in Registration/Insurance Related Denials!

– 32.15% Decrease in Medical Documentation Denials!

– 30% Increase in >180 aged claims Payments!

– 45.22% Decrease in Monthly Write Offs!

– Predictive v. Reactive Analytics!

Questions

Adam Gobin

Director, Revenue Management

@AdamGobin