The Ultimate Playbook for Mastering Claims Denials and Winning Appeals
The Danger of Silos
“For healthcare organizations to survive, their stakeholders must work together to safeguard and defend revenue, as no single person or department can do it alone. The non-siloed model is the future of patient care.”
Silos pose a significant threat to healthcare organizations, particularly when it comes to claims denials. These silos can often remain unnoticed for long periods of time, and stakeholders may be oblivious to their existence. When organizations operate in silos, they miss out on the collective knowledge and problem-solving skills of experts across the organization. The first step to overcoming silos is to acknowledge their existence. By breaking them down, organizations can focus their brainpower, control claims denials more effectively, and prevent revenue loss. Claims denials are complex and multifaceted issues that cannot be solved by a single person or department alone. To tackle this problem effectively, it is important to identify and collaborate with the right stakeholders in an organization who can leverage their diverse expertise and perspectives. The key is maximizing each person’s contribution by leveraging their strengths to achieve a synergistic outcome greater than the sum of its parts. While this paper primarily focuses on the roles and responsibilities of specific stakeholders such as HIM, CDI, and Case Management, it is important to recognize all stakeholders within an organization who can be part of the solution for claims denials, including Physician Advisors, IT, and Patient Financial Services. It is advisable to create a map of the route a denial takes in a specific organization to identify all stakeholders involved, as they may vary between organizations. An often-overlooked department that can help fight claims denials is Payor Contract Management. Contract renegotiations between healthcare organizations and payors are common, but if these changes are not communicated to all key stakeholders by Contract Management, the organization is at increased risk of claims denials. For instance, if Patient Registration is not informed about contractual changes in the process of obtaining prior authorization from a patient’s health plan before providing a service, it can lead to prior authorization denials. Similarly, the Utilization Review team should be informed of any changes in the cadence of required continued stay reviews to avoid medical necessity denials.
Clearly, a cross-functional team working together towards a common goal can achieve better results faster than if the same people work independently without
frequent communication. However, the road to organization-wide collaboration is challenging and requires committed, forward-thinking individuals willing to invest time and determination. Despite the challenges, the long-term benefits of achieving collaboration across the organization are invaluable. To have a successful claims program, healthcare organizations must harness their power and work smarter than ever before.
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