Five Actions to Bolster Payment
"We've also added our utilization review (UR) team, since payers have a UR clinician, so everyone is talking the same language and determines an action plan."
"We hire good customer service people with experience at department stores, restaurants, and other places involving aggravating situations with consumers."
—Donna Graham, senior director of revenue cycle at MetroHealth System in Cleveland, Ohio
UnityPoint Health, an integrated health system in Iowa, Illinois, and Wisconsin with $4 billion in net revenues, is taking a more assertive approach with payer terms.
"We're working to get shared savings," says Renee Rasmussen, vice president of revenue cycle. "We're also issuing termination notices to third parties for things that aren't right such as denials, and holding insurance companies more accountable."
2. Minimize denials through staff performance, improved documentation, and involving clinicians.
"The major source of waste is first-pass denials," says Patrick McDermott, vice president of revenue cycle at Sutter Health, a not-for-profit healthcare system based in Sacramento, California, with 24 hospitals, 5,500 physicians, and an ambulatory network.
"If you submit 1 million claims a year, 8% to 15% of them will get an immediate denial. And if it's not a key performance indicator, then it's a blind spot for someone running the revenue cycle," he says.
McDermott's strategy was to assign his entire team the responsibility of reducing denials and tying it to performance evaluations. His approach brought positive outcomes.
MetroHealth has minimized denials by attaching a summary of key indicators to the top of the medical record chart. Graham says a concise write-up makes it easier for insurers to review the claim. "It also puts the onus on payers to justify why they're denying it," she says.
Critical to refining claims submissions is engaging physicians and case managers.