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PROPRIETARY & CONFIDENTIAL

A Cross-functional Approach to Denial Prevention and Management

October 2017

THE DENIALS CHALLENGE

PROPRIETARY & CONFIDENTIAL2

Rick Childs, FHFMA,

Vice President,

Revenue Cycle

Management, Floyd

Medical Center

Presenters

Tony Rinkenberger,

Director of Revenue

Cycle, Ridgeview

Medical Center and

Clinics

Carmen Sessoms,

FHFMA, Associate

Vice President, RCM

Advisory Services

Program, Change

Healthcare

3

PROPRIETARY & CONFIDENTIAL

The Impact of Denials

Carmen Sessoms, Associate Vice President, RCM Advisory

Services Program, Change Healthcare

PROPRIETARY & CONFIDENTIAL4

Denials: An obstacle to timely and complete

reimbursement

PROPRIETARY & CONFIDENTIAL5

Denial rates by region

Alaska

Hawaii

PR VI

Pacific 10.89%

South Central 10.5%

Mid-West 10.32%

Southeast 9.33%

Southern Plains 8.6%

Northeast 8.3%

Mountain 6.99%

Northern Plains 6.64%

PROPRIETARY & CONFIDENTIAL6

Denial causes

Front-End

Front-End/Mid-Cycle

Mid-Cycle

Back-End

Denial causes span the entire revenue cycle,

although the largest percentage are associated with front-end processes.

PROPRIETARY & CONFIDENTIAL7

Appealing denials is costly

PROPRIETARY & CONFIDENTIAL8

The Change Healthcare denials and appeals data was culled from a sample of more than 3.3 billion hospital transactions valued at $1.8 trillion. Change Healthcare analysts used primary institutional inpatient and outpatient claims processed by Change Healthcare in 2016, and the average charged amount and first denied amount for the 724 hospitals included in the claims sample. hospitals was then extrapolated from this sample data. An appeal success rate of 63%1and average reimbursement rate of 29%2were used to calculate the amount denied. The $118 per claim average appeal cost is based on Change Healthcare statistical averages for hospital customers. The data used for the analysis is based on internal Change Healthcare data, and may or may not be representative.

Source of denials and appeals data

1Based on Change Healthcare statistical averages for hospital customers.

2 9

PROPRIETARY & CONFIDENTIAL

Seven Denial Prevention

Strategies

PROPRIETARY & CONFIDENTIAL10

HIM An analytics-driven revenue cycle enables a cross- functionalapproach to denial prevention

Patient accessBilling / collection

Analysis and use of data

PROPRIETARY & CONFIDENTIAL11

Where are denials originating?

Patient Access and Registration

Insufficient Documentation

Coding/Billing Errors

Payer Behavior

Utilization/Case Management

Which has the greatest impact?

A certain physician

A particular service line

A specific payer

A certain type of code

A process redesign

The first steps in denials prevention -analysis

Root Cause

Determination

Prioritization

1. 2. Do you have this data? Is it accessible in a timely manner? Do you trust it?

PROPRIETARY & CONFIDENTIAL12

Denial ReasonNational

Registration/Eligibility23.9%

Missing or invalid claim

data 14.6%

Authorization/pre-

certification 12.4%

Medical documentation

requested 10.8%

Service not covered10.1%

Medical coding5.8%

Medical necessity5.8%

Untimely filing3.7%

Appropriateness of care3.4%

Do you check it consistently?

How often do you check it?

At scheduling

Three days before elective services

Day of service

During stay (interim billing)

Before submitting claim

If not eligible/covered, what is your process to inform patient of financial responsibility and other options?

3. Prevention strategy-eligibility

PROPRIETARY & CONFIDENTIAL13

Denial ReasonNational

Registration/Eligibility23.9%

Missing or invalid claim

data 14.6%

Authorization/pre-

certification 12.4%

Medical documentation

requested 10.8%

Service not covered10.1%

Medical coding5.8%

Medical necessity5.8%

Untimely filing3.7%

Appropriateness of care3.4%

How are you alerted to potential data

quality issues?

Are you applying business rules to

examine registration data to help ensure

Are there workflows in place to correct

errors in real-time?

4. Prevention strategy registration data quality

PROPRIETARY & CONFIDENTIAL14

Do you know the real reason your

claims are denied for authorization?

Was it obtained?

Was it expired?

Was it for the wrong procedure?

Was the authnumber not on the claim?

Do you have the appropriate medical

necessity business rules informing your process?

5. Prevention strategy prior authorization and medical

necessityDenial ReasonNational

Registration/Eligibility23.9%

Missing or invalid claim

data 14.6%

Authorization/pre-

certification 12.4%

Medical documentation

requested 10.8%

Service not covered10.1%

Medical coding5.8%

Medical necessity5.8%

Untimely filing3.7%

Appropriateness of care3.4%

PROPRIETARY & CONFIDENTIAL15

Secure Authorization

Identify Changes to Scheduled Procedures

Ordered vs. performed

Revised authorizations

Insurance Plan Changes

Real-time eligibility

Exchanges and unpaid premiums can lead to denials

Coverage change with plan year changes

Denial prevention starts in patient access

PROPRIETARY & CONFIDENTIAL16

Scheduling

Require insurance, appropriate codes and

authorization

Medical necessity

Record all calls and electronically capture digital image of authorizations from payer website

Authorization Team

Verify payers authorization requirements and correct authorization (obtains auth for physician offices) Record all calls and electronically capture digital image of authorizations from payer website

Denials prevention starts in patient access

PROPRIETARY & CONFIDENTIAL17

Pre-registration

Verify insurance eligibility and benefits, IP only and outpatient codes

Document in ADT

Record all calls and electronically capture digital image of authorizations from payer website

Registration Walk in, Direct Admits and STATS

Verify insurance eligibility and benefits

Medical necessity

Notify authorization team when needed

Denials prevention starts in patient access

PROPRIETARY & CONFIDENTIAL18

UR/Case Management

Updating clinical data for continued stay approvals Involve Medical Director when peer-to-peer is needed

Validate medical necessity

CDI Team

Educate physicians on documentation issues that lead to denials.

Denial prevention continues in mid-cycle

PROPRIETARY & CONFIDENTIAL19

$796,471$791,065 $100,000 $200,000 $300,000 $400,000 $500,000 $600,000 $700,000 $800,000 $900,000

PARAGON -Point of Service Collections20152016

2017Goal

Note: Goal based on 2011 KPIs.

Analysis drives targeted education to help prevent denials

PROPRIETARY & CONFIDENTIAL20

Eligibility verification improvement and stabilization

PROPRIETARY & CONFIDENTIAL21

Registration quality improvement and stabilization

PROPRIETARY & CONFIDENTIAL22

6. Prevention (and management) strategies effective

claims process

Strong Edits

Claim Visibility

Appeal Denied Claims

To help submit

clean claims

To enable proactive

issue resolution

To help recover

potential revenue

Copyright 2017 Change Healthcare Operations LLC and/or one of its subsidiaries and affiliates. All Rights Reserved.

PROPRIETARY & CONFIDENTIAL23

the revenue cycle Payer

RelationsReimbursement

Denial Analysis

Billing Efficiencies

Services Rendered

Patient Access

PROPRIETARY & CONFIDENTIAL24

Regularly seek facts and implement change

Implements

change

Invests in skills

and technology

Seeks factsSeeks facts

Implements

change

PROPRIETARY & CONFIDENTIAL25

Patient Financial Services

Build edits in your host system and/or claims scrubber

Tailor edits to the payer

Denials Team

Involve the front-, middle-and back-end departments Track denials by payer, denial type, department, etc.

Find the trends

Focus on largest denials by volume and dollar

Create focus groups with all departments involved to find and correct the root cause of denials

Denial prevention in the claims process

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