1 Tracey Tomak RHIA PMP Senior Director Project Management and Client Engagement Intersect Healthcare Inc Towson MD 2 Title Version C Learning Objectives At the completion of this educational activity the learner will be able to ID: 781131
Download The PPT/PDF document "Denial Prevention: Addressing Root Caus..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Denial Prevention: Addressing Root Causes through Data Analytics and a Team-based Culture
1
Slide2Tracey Tomak, RHIA, PMP
Senior Director, Project Management and Client Engagement
Intersect Healthcare, Inc. Towson, MD
2
Slide3Title Version C
Learning Objectives
At the completion of this educational activity, the learner will be able to:
Define data, data analysis, information and knowledge management
Identify key contributors of data in various healthcare settings
Clearly distinguish the difference between Reason Code, Issue and Root Cause
Determine what data elements are relevant for analysisEstablish an action plan based on the information obtained from data analysis (including reports and key stakeholders)
3
Slide44
Defining Data Analytics
Slide5Data - Defined
5
facts and statistics collected together for reference or analysis
the quantities, characters, or symbols on which operations are performed by a computer, being stored and transmitted in the form of electrical signals and recorded on magnetic, optical, or mechanical recording media.
Webster’s Dictionary
Slide6Data – Examples of Revenue Cycle Data
6
Primary Diagnosis Codes
Secondary Diagnosis Codes
Procedure codes
Revenue Codes
Hospital Service Codes
Attending Physician
Ordering Physician
Operating Physician
Admit Source
Slide7Data Analysis - Defined
7
1.
A resolution of anything, whether an object of the senses or of the intellect, into its constituent or original elements; an examination of the component parts of a subject, each separately, as the words which compose a sentence, the tones of a tune, or the simple propositions which enter into an argument. It is opposed to synthesis.
3.
(Logic)
The tracing of things to their source, and the resolving of knowledge into its original principles
Webster’s Dictionary
Slide8Data Analysis – Within the Revenue Cycle
8
Diagnosis and Procedure Codes – Are they supported by the documentation? Volume by physician, by hospital service?
Revenue Codes – Are they appropriate for the setting? Are the correct units reported?
Hospital Service Codes – Assists when drilling down to where certain patterns are appearing in the organization.
Type of physician – Just because the Attending MD is reported on a case with an error, do not be quick to place fault on the attending MD. Consider also the type of service (consulting specialist or surgeon for example)
Admit Source – Was the admit source captured appropriately? (example – urgent, direct admit, emergent)
Slide9Information - Defined
9
1.
The act of informing, or communicating knowledge or intelligence.
2.
Any fact or set of facts, knowledge, news, or advice, whether communicated by others or obtained by personal study and investigation; any datum that reduces uncertainty about the state of any part of the world; intelligence; knowledge derived from reading, observation, or instruction.
Webster’s Dictionary
Slide10Information – Revenue Cycle Information
10
Diagnosis and Procedure Codes – insufficient documentation is present, Dr. X’s patients have the highest percentage of sepsis compared to other specialists in the same service line.
Revenue Codes – There are multiple units of Revenue Code 360 being reported on a single day out of ambulatory surgery in Pavilion B only.
Hospital Service Codes – Service code CAR had 50K written off last month due to Reason Code 197 (authorization issue).
Type of physician – Dr. Z is an attending in CAR.
Admit Source – 100 cases were denied by Anthem last week and all were billed with Admit Source = Urgent.
Slide11Knowledge Management -Defined
11
Efficient handling of information and resources within a commercial organization.
Oxford English Dictionary
Slide12Knowledge Management – Revenue Cycle
12
Information:
Hospital Service Codes – Service code CAR had 50K written off last month due to Reason Code 197 (authorization issue)
Knowledge Management (transforming the information into relevant context and determining next steps):
For Example:
95% of the write-offs for lack of auth were for one test, one insurance payer and came out of CAR. Need to follow-up with staff to determine how they are obtaining or NOT obtaining authorizations for this test and establish a new process OR discuss with the payer if this is not a requirement found in the payer manual or contract.
Slide1313
Revenue Cycle Data Sources
in
the Healthcare Setting
Slide14Common Data Sources - Admitting
14
Patient demographics
Payer and payer plan information
Financial Class
Admitting/ordering physician
Authorization information
Admission Date and time
Service Site
Service Type
Test ordered
Discharge Date, disposition and time
Slide15Common Data Sources - Charging
15
CPT service/procedure codes
Revenue codes
Charged units
Line item Description
Unique charge code
Modifiers
Line item charge amount
Slide16Common Data Sources –Coding/Abstracting
16
Diagnosis codes
Procedure codes
DRGs
APCs
HACs
Physicians – Attending, consulting, operating
Admit Type
Discharge disposition
Modifiers
Slide17Common Data Sources - Billing
17
Condition codes
Modifiers
Occurrence codes
Billed units
Non-covered charges
Bill type
Slide18Common Data Sources –
EOB/remittance
and Follow-up18
Reason Codes
Issues
Write-off codes
Denial and variance volumes
Audit volumes
Audit outcomes
Root Causes
Medical Record Requests (Pre-pay and post-pay : RFI, ADR, etc.)
Contractual Adjustments
Line level vs. claim level adjustments/denials
Slide1919
Distinguishing between Reason Code, Issue
and
Root Cause
Slide20Reason Code
197- Payment adjusted for
absence of recertification/ authorization.Issue
No Auth at all
Wrong Auth
Wrong date of service
Wrong CPT code Wrong SettingMissed recertification – Length of stay, Level of care, number of visits20Reason Code 197 versus Denial “Issue”
Slide21Reason Code
50- Non-covered: Not Medically Necessary
IssueWrong settingLack of approved diagnosis for test/service
Lack of documented prior “conservative treatments”
Maximum billable units exceeded
21
Reason Code 50 versus Denial “Issue”
Slide22Reason Code
197- Payment adjusted for absence of recertification/
authorization.Root Cause
No attempt
Different service/test ordered than performed
Rescheduled to a different date of service- no notification to the payer
Documentation does not support IP level of careNo attempt to add days to an inpatient stay beyond initial certificationFailure to request approval for additional rehab visits22Root Cause for Denial Reason Code 197
Slide23Reason Code
50- Non-covered: Not Medically Necessary
Root CauseDocumentation does not support IP level of care
Lack of documented specificity in reason (sign/symptom/diagnosis) for service
Lack of documentation on the facility record
Unaware of medical policy or documentation not supporting the need for more units.
Charge or coding error23Root Cause for Denial Reason Code 50
Slide2424
Determine relevant data elements for analysis
Slide25Knowing the Audience – Who cares? And Why?
25
C-Suite
– High-level volume of cases and $$ at risk or fatal
Clinical Directors
– charging and documentation issues specific to their oversight
Revenue Cycle Leaders
– Admitting, Registration, Scheduling, Coding, CDI, Billing, Follow-up, Chargemaster, Revenue Integrity
Managed Care/Contract Management
– patterns of abuse by payers
Payers
– combat misuse and disputes with data
Physicians
– why does it matter to them?
Information Services
– lack of proper interfaces, unable to collect supporting documents from EMR
Slide26Sample Report – High Level
26
No Precert/Authorization Quarterly Denials - Chart
This chart can be used as a management educational tool.
Slide27Sample Report – Line Level from 835/EOB
27
Line Item Adjustments from the Primary Payer - Current Month
A management report that you can see your line item denial reasons and the adjusted dollars by facility, payer, revenue center.
Remit Date
Insurance Payer
Reason CD
Reason Code Description
Proc CD
Procedure Code Description
Revenue CD
Revenue Code Description
7/28/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0250
0250
Pharmacy - General
7/28/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0300
0300
Lab - General
7/13/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0300
0300
Lab - General
7/28/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0301
0301
Lab - Chemistry
7/28/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0301
0301
Lab - Chemistry
7/28/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0301
0301
Lab - Chemistry
7/28/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0301
0301
Lab - Chemistry
7/13/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0302
0302
Lab - Immunology
7/13/2018
TX-Blue Cross Blue Shield of Texas
11
Diagnosis inconsistent w/ Procedure.
0302
0302
Lab - Immunology
Slide28Sample Report (Graph) – Audit Issue (Reason Code)
28
Audit Issues For The Current Year Trend
This report is trending the audit issues by the notice date of the ADR/Denial.
Slide29Sample Trending Report –
Audit Issues with At Risk $$ and # of cases
29
Audit Issues For The Current Year Trend
This report is trending the audit issues by the notice date of the ADR/Denial.
# of Cases
Audit Issue
Initial At Risk
Expected Reimbursement
Initial Appealed $
Total Appeal Recovered $
2
Authorization was not obtained for one or more days of inpatient stay
$369,811.61
$360,902.46
$8,909.15
$0.00
2
Commercial - Experimental/Investigational
$62,213.00
$92,909.13
$0.00
$0.00
950
Commercial - Inpatient Setting Not Medically Necessary
$28,285,231.79
$5,052,664.76
$24,094,456.42
$5,405,777.96
2
Coordination of Benefits issue - Primary insurance not billed first / pre-auth not obtained
$38,323.34
$31,874.50
$0.00
$0.00
6
GOVT-MEDICAL NECESSITY DENIAL
$427,393.97
$324,597.37
$0.00
1
GOVT-PATIENT TYPE DENIAL
$10,020.07
$10,020.07
$0.00
21
Medical Necessity
$700,456.64
$227,132.56
$503,999.04
$21,261.90
1
Medical Necessity of Transcatheter Mitral Valve Replacement Procedures
$105,240.37
$105,240.37
$0.00
$0.00
2
Pre-authorization not obtained due to no insurance on account at time pre-auth required
$46,378.06
$46,378.06
$0.00
$0.00
202
Readmission within 30 days
$11,360,914.80
$3,881,051.20
$8,488,394.89
$660,890.45
17
RETRO-LEVEL OF CARE DENIAL
$682,651.26
$603,909.87
$630,567.38
$0.00
3
RETRO-MEDICAL NECESSITY DENIAL
$93,711.70
$93,711.70
$10,914.79
373
RETRO-PRE-CERT DENIAL
$12,876,201.24
$4,717,329.67
$9,216,843.03
$1,221,577.29
363
Service Requires Authorization
$14,735,372.10
$3,526,141.34
$12,453,121.71
$2,354,508.61
Slide3030
Reporting Data to
“
Drill down to the Root Cause”
Slide31Sample Trending Report (Graph) –
Root Cause by case created
31
Root Cause For The Current Year Trend
This report is trending the root cause by the case created date of the ADR/Denial for the current year.
Slide32Sample Trending Report (Detail)–
Root Cause by case created
32
Root Cause For The Current Year Trend
This report is trending the root cause by the case created date of the ADR/Denial for the current year.
# of Cases
Root Cause
Initial At Risk $
Expected Reimbursement
Initial Appealed $
Total Appeal Recovered $
2
Billed principal diagnosis not present at admission
$99,439.11
$99,439.11
$82,847.95
1
Billed Principal Diagnosis not principal reason
$9,536.43
$9,536.43
$9,536.43
2
Case Created in Error
$22,858.72
$0.00
$0.00
4
Coding Error
$70,542.64
$28,988.05
$28,988.05
3
Duplicate Case Entry
$55,038.83
$0.00
$0.00
1
Experimental or
Investigational
$39,354.51
$0.00
$0.00
97
Level of Care
$3,261,097.92
$481,886.12
$2,323,284.75
$487,194.75
16
Missing or Additional Documents Required
$723,398.71
$14,692.02
$166,609.00
$0.00
5
No Inpatient Order
$89,558.98
$28,452.88
$0.00
$0.00
125
No Pre-certification/No Authorization
$6,502,541.82
$582,894.17
$6,321,550.24
$915,663.54
252
Not Medically Necessary
$7,499,643.07
$168,285.42
$6,516,640.38
$1,767,074.79
167
Other: Explained in Notes
$3,992,295.05
$3,698,749.78
$77,965.59
1
Past Timely Filing - See Notes
$28,022.96
$0.00
$0.00
1
PH-AUTH-Clinical not submitted or not submitted timely
$39,851.10
$40,332.70
$39,851.10
$0.00
1
PH-AUTH-No authorization
$69,372.41
$69,372.41
$0.00
Slide3333
Establishing an action plan based on the information obtained from root cause
data
analysis
Slide34Root Cause Analysis
34
In Slide
30
we can see that this organization has issues with denial issues that are both recoverable (by appeals) and fatal (not recovered even when appealed)
We can also see that there are issues recovered which account for high volume and low volume # of cases
Additionally, we can see initial at risk vs. recovered $
With this little bit of analysis, we can begin to identify those trends that we will want to investigate and form an action plan for denial prevention
Slide35Root Cause Analysis - Prioritizing
35
Priority
# of Cases
Root Cause
Initial At Risk $
Expected Reimbursement
Initial Appealed $
Total Appeal Recovered $
1
252
Not Medically Necessary
$7,499,643.07
$168,285.42
$6,516,640.38
$1,767,074.79
2
125
No Pre-certification/No Authorization
$6,502,541.82
$582,894.17
$6,321,550.24
$915,663.54
3
97
Level of Care
$3,261,097.92
$481,886.12
$2,323,284.75
$487,194.75
4
2
Billed principal diagnosis not present at admission
$99,439.11
$99,439.11
$82,847.95
5
167
Other: Explained in Notes
$3,992,295.05
$3,698,749.78
$77,965.59
Slide36Root Cause – Action plan
36
Issue 1 – Not Medically Necessary
Pull the detail on the 252 cases and drill further down by hospital service, service type, payer, etc.
Review detailed notes from admitting, case management, appeals, etc.
Identify any trends that may be present among the cases
Meet with key stakeholders where patterns/trends exist to develop an action plan for Process Improvement (PI)
Examples of PI: Retraining for UM/CM staff on use of clinical care guidelines such as Interqual or Millimen, use of peer-to-peer opportunity, use of MD Advisors, payer discussion, documentation improvement, etc.
Slide37Root Cause – Action plan
37
Issue 2 – No Pre-certification/No Authorization
Pull the detail on the 125 cases and drill further down by hospital service, service type, payer, etc.
Review detailed notes from admitting, case management, appeals, etc.
Identify any trends that may be present among the cases
Meet with key stakeholders where patterns/trends exist to develop an action plan for Process Improvement (PI)
Examples of PI: Retraining for scheduling, admitting, case management, physician offices, etc.
Slide38Root Cause – Action plan
38
Issue 3 – Level of Care
Pull the detail on the 97 cases and drill further down by hospital service, service type, payer, etc.
Review detailed notes from admitting, case management, appeals, etc.
Identify any trends that may be present among the cases
Meet with key stakeholders where patterns/trends exist to develop an action plan for Process Improvement (PI)
Examples of PI: Retraining for scheduling, admitting, case management, physicians, discussion with specific payers and contract management, etc.
Slide39Root Cause – Action plan
39
Issue 4 – Billed principal diagnosis not present at admission
Pull the detail on the 2 cases and provide feedback to coding for review
This is a low volume issue with high potential $$ and possibly a training issue
Slide40Root Cause – Action plan
40
Issue 5 –
Other: Explained in Notes
Pull the detail on the 167 cases and drill further down by hospital service, service type, payer, etc.
Review detailed notes from admitting, case management, appeals, etc.
Identify any trends that may be present among the cases
Meet with key stakeholders where patterns/trends exist to develop an action plan for Process Improvement (PI)
This issue may require further root causes to be built if additional patterns are identified
Perform PI as needed
Slide4141
Summary
Slide42Summary
42
In order to prevent denials in the future, it is important to collect valid data based on actual root cause rather than simply relying on the reason codes returned by payers on 835/EOB/remittances.
This data can become valuable information when reported and analyzed for patterns and trends.
Slide43Summary
43
When appropriately collected and analyzed, this information can be used to further define the service site, service type, payer and possibly physicians where the issues are originating and education and training can be offered to decrease denials caused by internal failures.
This information may also be used in discussion with payers to establish specific contract terms regarding payment and appeal rights.
Root Cause analysis is not a revenue cycle only matter – this effort will require breaking down silos and having honest discussions about internal processes that may require re-education, training and/or revision.
Slide4444
Thank you. Questions?
Tracey A. Tomak, RHIA, PMP
ttomak@intersecthealthcare.com