MSHIMA | Decoding Payer Denials: Transforming Challenges into Revenue Optimization Opportunities

Payer denials are ever increasing on all fronts in both the inpatient and outpatient setting under the guise of medical necessity and clinical validation denials as well as DRG and level of care downgrades. Providers receive denial letters outlining their rationale for the denial, often with generic nonspecific terminology and rationale. Payer denials are generally thought of as an added cost of doing business, adding an expense line to the financial statement. Forward thinking organizations view denials as part of a continuous quality improvement initiative centered around improving revenue cycle processes with a focus upon identifying and focusing upon the weakest link under the theory of limitations. Decoding payer denials must be conducted and facilitated through the mindset of learning and continuous quality improvement with the deployment of clinically astute staff that embrace the mission  of “Proactive Preemptive Denials Avoidance.”

Objectives:

• Creating an organizational vision and mission that embraces the notion of “Do It Right the First Time”
• Learn how to motivate all revenue cycle staff to and think proactive preemptive denials avoidance
• Hire, train, and motivate staff that changes and instills a culture of patient first supported by optimal net patient revenue streams
• Learn how to interpret payer denial letters and read between the lines of the denial letter
• Recognize and identify payer denial trends and formulate an effective denial mitigation strategy
• Deploy and share Key Performance Indicators that validly and reliably measure revenue cycle denials avoidance performance.