Our work reducing surgical denials by 40%+
For independent orthopedic providers, surgical denials mean unacceptable delays in revenue.
What would it take to dramatically reduce the number of surgical denials our client received?
Here are the 6 steps we took to achieve this in 6 months.
Make the denials data clinically relevant.
Denials are simply messages from the insurance company saying “we are not going to pay on this claim”. To get to root causes, these denials need to be interpreted clinically. What specialties? What procedures? What surgeon? Many providers do not have the ability to tie denials data back to their source cases easily, but this is an essential first step. We found a significant concentration of denials in sports medicine and to a lesser degree in joint replacement and spine related to medical necessity and prior authorizations.
2. Get the clinic and facilities talking.
Even without data, chances are the facilities can tell a clinic something about challenges with surgery reimbursement (and vice versa!). After all, both claims are going in and each billing team will be getting part of the picture back from the insurer. Comparing notes is a helpful first step, and can lead to better process coordination and ultimately better patient experience when everyone is on the same page about insurances, networks, and orders.
3. Look at the order.
No, really look.
The decision for surgery is an important one, and the plan for surgery is precise. We found that the “words” on the order (the procedure the surgeon intends to perform) did not always match the “numbers” (the CPT codes being authorized). The downstream effects of this are often hidden. Authorizations may go in for only some of the appropriate codes. Patient consent may be vague. Block time may be booked incorrectly. Everyone assumes everyone else understands the plan, but of course you know what they say about assuming…
4. Ask the coding experts.
Some orders are much more complicated than others. For those that clinical teams or surgery schedulers may not be 100% certain on, a 2 minute consultation with a certified coder can make all the difference. Especially when it comes to medical policies, bundling, and CCI edits, coding knows what they’re talking about. We created a dedicated communication channel that provides real-time input for everyone involved and improved the accuracy of coding from the start.
5. Auth early and often.
Armed with the right codes, the authorization process can go much more smoothly because the clinicals will more closely match the codes being authorized. This alone leads to fewer peer to peers and misunderstandings. But there will always be intraoperative findings that mean the surgical plan needs to be adapted to clinical circumstances. In these cases, a retro authorization (sometimes called a post-service review) is recommended. These may need to be started the same day of the procedure, so we set up a secure voicemail to enable providers to let us know one was needed. It helps to have the facilities on board and looking out for this (see step 2!)
6. Don’t be shy about the impact.
Change management is always important, and justifying the need for these process changes to all parties is essential. The coders need to know why they have to code the orders now, again? The doctors need to know that making the retro auth phone call is worthwhile. Ultimately we needed to know whether we were doing the right thing. So tracking the denial rates and incremental revenue associated with these cases made all the difference. We went from 1 in 30 surgeries being denied to 1 in 55 within 6 months and we have sustained that improvement over time.