Denials Management Using Optimum RCM and Best Practices Ken Miller, Senior Managing Consultant, NTT DATA

Transcription

1 Denials Management Using Optimum RCM and Best Practices Ken Miller, Senior Managing Consultant, NTT DATA 09/11/2016 Date of Presentation 2016 NTT DATA Client Conference Copyright 2016 NTT DATA Corporation

2 Index 01 Introduction 02 Denial Trends 03 Optimum and Denial Management 04 Process Best Practices 05 Demo of New Reports and Libraries 06 Conclusion 2015 NTT DATA, Inc. 2

3 Introduction 2015 NTT DATA, Inc. 3

4 Denial Management Denials management is a complex process Reactive Approach Proactive Approach Industry Trends Only 35% of providers actively pursue denied claims 1 Average Days in AR is 26 for all payers 1 Denial rates increasing Best Practices are not unified Small vs Large Provider differences Denials Team or Task Force Process from claim Patient Access through Collections has to be connected Optimum RCM Denials Management Developing standardized libraries for EDI and claim codes Developing new standard reports Developing best practice AR processing rules library Demo and Round Table! 1. Beckers Hospital Review: 4 Key Insights into Payer Efficiency, Transparency, Payment Speed and More, Copyright 2016 NTT DATA Corporation 4

5 Denial Trends 2015 NTT DATA, Inc. 5

6 Approaches to Denials Management Reactive Approach Traditional wait for denials, then shift to denials specialists to work Relies on workflow reporting Produces some level of metadata on its own about upstream issues Proactive Approach Evolves from Reactive Approach Trend out denials by type and hone in on fixing technical denials before they occur Claim scrubs to catch missing information Focus on eligibility verification Billing Rules specific to payers to add comments into accounts where a procedure will be denied by plan policy Reports on trending are handed to a task force that gets involved in Patient Access through Collections as needed Copyright 2016 NTT DATA Corporation 6

7 Industry Trends If only 35% of providers pursue denials why? Cost to pursue Assume an average labor cost $24/hour, with benefits - $32 Assume overhead cost at 15% (total all non-labor business office annual costs, divide by FTEs then 2080 for your per hour cost) $36.80 per hour of work Non-technical denials that require clinical oversight have an even higher cost structure Not enough FTEs to dedicate to a task force, may share role with others Not enough data on money missed If you do pursue denials what is your appeal success rate? If you don t pursue denials what is your denial rate? Copyright 2016 NTT DATA Corporation 7

8 Days in AR Average 26 Days in AR for all payers where do you stand? Varies by market and payer mix Independent of provider processing time Denials can immediately double the time Pre-authorizations integrated with Scheduling? Registration data quality integrated with Eligibility? Coding and HIM review process upon denial? Total time pre-final bill? Total time post-receipt of determination? Copyright 2016 NTT DATA Corporation 8

9 Denial Rates Denial rates have been increasing Up to 18.5% for Medicaid (Important with the ACA) Nearing 6.8% on average for all other payers New Quality denials have started and are set to increase into the future Usually not a full claim denial May show up as an underpayment Result of either: Not submitting the appropriate Quality Indicator Not achieving a quality target Need new reports and analysis Most payers report that 2/3 denials are appealable, leaving the appropriate rate at 6.1% for Medicaid and 2.3% for all other payers What denial rates are you seeing? Copyright 2016 NTT DATA Corporation 9

10 Optimum and Denial Management 2015 NTT DATA, Inc. 10

11 Background Overview Certain modules interact together to allow denials tracking and workflow Invoice tracking pa6850.sh dayend script 835 Processing ARPS rules Contract Management Work Queues (ARMS Collector Work Queues, or AR Work Queues) ecq/dashboard ARMS High Level Approach what we identified System has the ability to track denials and report on them, as well as channel corrections into work queues To support existing functionality we need to: Offer standard libraries for denials metadata (CARC/RARC, Claim Status codes, etc) based on CMS Standards Based on the CMS Standard data, have ecq reports/dashboards for denials Based on the CMS Standard data, have a suite of ARPS rules for common denials to push them into workqueues Copyright 2016 NTT DATA Corporation 11

12 What we ve done and what we re working on Finished: Identified all the modules and functions that need to be enabled to support Denials Management Built standard ecq reports that we can deploy and train you in the use and customization of Built standard libraries that we can deploy into your environment to aid the process Can offer guidance and consulting packages to get you started using Optimum RCM for denials management To be completed (Expected Date TBD) Re-organizing functions into a new function heading: Denials Management Begun building of standard ARPS rules for deployment (will be refined with feedback from firstadopter sites) Copyright 2016 NTT DATA Corporation 12

13 Process Best Practices 2015 NTT DATA, Inc. 13

14 Process Best Practices We want to enable: Overall reporting on denials Sorting by type and frequency Sorting by functional group for disposition Allow for report customization once specific targets are identified Work Queues and ARPS rules for claim scrubbing Integrate with workflows in ARMS Provide some standard rules for you to reference when setting up your billing process Standardize some libraries CMS standard values will be available, and loadable upon request Allows more robust use of the Invoice Tracking feature Create denials management functions in Optimum RCM Copyright 2016 NTT DATA Corporation 14

15 Process Best Practices Denials Team Should include cross-functional team members Clinical Patient Access Scheduling Billing Collections HIM/Coding Should have a project lead coordinating and updating status on: Risk Assessments Project review Analysis results Policy and Procedure updates/changes Copyright 2016 NTT DATA Corporation 15

16 Process Best Practices Billing rules Reviewed regularly Common technical denials addressed with pre-claim rules and notifications Rotation review selected subsets of rules are analyzed every month for efficiency and applicability Issues arising from Quality denials are forwarded to a subcommittee that interfaces with the provider s Quality department Full internal audits are performed quarterly and reported on in the committee meeting with executive oversight Full external audits are requested annually to garner outside recommendations and solutions with executive oversight Copyright 2016 NTT DATA Corporation 16

17 Demo of New Reports and Libraries 2015 NTT DATA, Inc. 17

18 Demo Discussion What did you like? What do you want to see more of? What opportunities for improvement should we look into? What other questions do you have? Copyright 2016 NTT DATA Corporation 18

19 Conclusion 2015 NTT DATA, Inc. 19

20 Conclusion Wrap up of discussion Please feel free to reach out to your account executives if you would like to talk about being a first adopter, and help in the refinement of the product We will be putting together a webinar to demo the functionality to a wider audience, more details will be provided on the client-only website soon. We look forward to your input! Thank you! Ken Miller Senior Managing Consultant, HC & LS Ken.Miller@nttdata.com m nttdata.com/ushealthcaretechnologies NTT DATA, Inc. Consulting Digital Managed Services Industry Solutions Learn more: Copyright 2016 NTT DATA Corporation 20

21 Copyright 2016 NTT DATA Corporation (Please omit notations when unnecessary) This document contains confidential Company information. Do not disclose it to third parties without permission from the Company.