How Orlando Health Drove Down Claims Denials
The nonprofit network reversed an upward trend in claims denials, with the month-to-month denial rate reduced to as little as 1%.
Since 2012, Orlando Health has conducted concerted efforts inside and outside the health system's revenue cycle team to decrease claims denials, which were trending above 5% on an annual average basis.
"It was a high-priority project because our denials were increasing," says Bridget Walters, corporate director of enterprise patient access.
The claims-denial prevention efforts, which are ongoing, have reduced claims denials significantly, with monthly claims-denial rates as low as 1%, she says, adding the average annual denial rate is about 4%.
Coordination and Accountability
One of the first claims-denial initiatives Orlando Health launched was the creation of a denials management team with existing staff members that focused on claims denials enterprise-wide, including the health system's seven acute-care hospitals.
Walters says the denials management team featured top-notch employees drawn from three areas at Orlando Health facilities: collectors, billers, and nurses.
"We had a total of 14 individuals on the team who were star performers in their areas," she says.
The primary focal points of the denials management team, which met on a weekly basis, was denials prevention and large-claim denials.
Once the denials management team started identifying trends, Walters says it took several systematic actions to prevent claims denials:
- Worked with department executives to incorporate claims-denial prevention mechanisms in workflows
- Conducted "road shows" to meet with nurses and other key staff members at the health system's hospitals and clinics to discuss claims-denial trends and collaborate on claims-denial prevention
- Tracked claims denials as avoidable or unavoidable, then shared those categorizations with all affected areas such as coding, revenue integrity, physician practices and scheduling
- Educated the clinical team on the medical necessity guidelines for inpatient admissions
With the health system's denials prevention effort matured and optimized, the denials management team has shrunk to seven members and meets monthly. The team is staffed with patient-access managers, who are not only continuing the claims-denial prevention activities of their predecessors but also closely supervising registration staff to prevent patient-access-related claims denials.