Transcript ETACTICS
presents Establishing a Lean Quality Approach to Denial and Appeal Management Is the glass half empty… …or half full? The Staggering Cost of Denials High denial rates impact both the speed at which you get reimbursed and the administrative costs associated with being reimbursed. It is estimated that the cost of claims rework is as high as 20% of overall revenue cycle operating costs.1 1. Steven Huddleston, “Creating a Healthy, Unified Revenue Cycle” HFMA Revenue Cycle Strategist, November, 2012 An additional 6% of gross revenue is lost to underpayments.2 Nearly 13% of annual provider revenue is at risk to payer denials nationwide.2 2 . “Keys to Effective Denial Management” Emdeon Compass, March, 2010 ICD-10 Implementation Fable of the Lion & the Gazelle Lean Process Improvement Henry Ford Production Line Efficiency — Flow The Revenue Cycle Production Line Raw Materials • Denials • Zero Pays • Short Pays • Chart Review Requests Production Process Finished Products • Identifying • Analyzing • Qualifying • Rebills • Adjustments • Appeals Quality Control • Measuring KPI’s • Timing • Sequencing • Inspection • Supervision Lean Process Transformation Kaizen Change Taiichi Ohno Toyota Production System - TPS 1. Produce only what the market wants 2. Use visual aids to highlight where action is needed 3. Use small batch sizes Good Continuous Improvement Lean Process Problem Solving Dr. W. Edwards Deming PDCA PDSA Don’t let perfect get in the way of better One improvement often leads to another Standardized Work Source: lean.org Standardized Denial Processing Eliminating Waste – Muda D O W 6 N Defects Effort caused by omissions and incorrect information. Over-processing More work or higher quality than is required. Waiting Wasted time waiting for the next step in a process Non-Value Added Processing Processes that do not add value. T I M E Transportation Unnecessary movements of documents and files. Inventory Excess denials, zero pays & short pays not processed. Motion Unnecessary movement by people (e.g. walking). Employee Underutilization Underutilizing staff talents, skills & knowledge Defects Over-processing Waiting Non-Value Added Processing Motion Employee Underutilization Inventory Root Cause Analysis The Underlying Causes No Authorization Eligibility Issues “The Root” Billing Issues Information Required the Patient Coding Below thefrom Surface Information Required Coordination of Not Obvious from the Provider Benefits The word root, in root cause analysis, refers to the underlying causes not the one cause. Cost Outliers Duplicate Claims Non-Covered Services Untimely Filing http://www.thinkreliability.com/Root-Cause-Analysis-CM-Basics.aspx Root Cause Analysis Fishbone Diagram People Inadequate staffing in patient access Process/Policy Lack of coordination with registration Inadequate training Poor role definition Computer downtime Equipment Overcrowding Environment Denial Value Stream Value Stream Value Stream Mapping Process Value Stream Mapping Kit 2 days 2 days 1 Min/Avg .5 Hr Valid? Yes 4 days 1 days .5 Min/Avg 5 Min/Avg 2 days No 2 Min/Avg 2 days 2 days 10 Min/Avg 1 Min/Avg Reopen? Yes No 5 days 5 Min/Avg 4 days 8 days 2 Weeks 10 Min/Avg 15 Min/Avg 2 Min/Avg Await payer response Send appeal Write Appeal Gather Information Assign to appeal queue Correct and rebill Correct and Rebill queue Write-off or rebill Write-off or bill patient queue Review Denials Assigned Denial Queue Assign Denials Review Denials Denied Claims Kanban Kanban Board • Visualize, optimize and manage workflow • Enable real-time team collaboration • Make Process Policies Explicit Core Practices for Successful Kanban Adoption Shallow Visualize Workflow Manage Flow Make Process Policies Explicit Improve through Collaboration Kanban is based on 3 principles Manage Work in Process Start by Modeling Your Existing Process Denials Appeals Board Board Audit Board Workload Assignment & Management login ctrownson ▪▪▪▪▪▪▪▪▪▪ Home Home2 home3 payers aetna provider facility carc rarc user Tableview Denial_Queue Appeal – properly coded cerumen removal and modified E/M coding Denial_queue2 appeal_queue Questions