Denial Prevention Projects: Recent Successes

RemedyIQ is a healthcare consulting firm delivering solutions to streamline the healthcare reimbursement process. Their remedies help providers optimize existing technologies to reduce cost to collect, decrease the risk of denied claims, and improve your overall financial health. RemedyIQ empowers organizations with the tools, insights, and data-supported root cause they need to be successful.

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Through strategic analysis of denial volumes, RemedyIQ has partnered with healthcare organizations on denial prevention strategies to not only help prioritize and resolve open volumes, but to also systemically address upstream issues to reduce future denials. RemedyIQ believes the solution lies in process improvement for long-term health in tandem with short-term strategies to address backlogs and accelerate cash.

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Payor Strategic Partnerships

• Prior Authorization Workstream Enhancement – collaborate with payor to automate process for in-network providers to determine if prior authorizations are required and define/agree on turnaround timeframes 
• A/R Escalation Pathway – Aged A/R reviews to identify opportunities for both the provider and payor, document pathways for escalation of aged A/R and obtain mutual agreement to terms

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Automation

• Additional Documentation Requests for Itemized Bills – creation of scripts to capture requests and provide exports of Itemized Bills, decreasing days to submit and cost to collect
• Authorization Documentation on UB-04s – creation of scripts that update the referral numbers as authorization numbers when not populated prior to claim submission/nightly processing to reduce no-authorization denials 

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EMR Opportunities

• Epic CareLink – leverage Epic CareLink for authorization workflows to reduce submission of medical records requests to case management

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Patient Access Authorization Workflows

• Education – provided education on targeted procedures not being authorized by specific departments and then monitoring results/improvements

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Coding/Billing Opportunities

• Diagnosis Codes – identification of primary diagnosis codes or non-active billed in error that resulted in non-covered denials, partnered with coding to correct diagnosis code placement and select alternative coding
• Revenue Codes – identified HCPCS denials due to revenue code billed, partnered with payor and revenue integrity to determine appropriate revenue code and implement payor-specific billing rules
• Inclusive/Non-Covered Codes – identified HCPCS denied as inclusive/non-covered and partnered with coding/revenue integrity teams to identify alternative reimbursable codes
• Drugs & Biological Documentation – identified NDC billing issues (i.e., not billed, incorrectly billed) and established workflow modifications to prevent billing error denials

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Post Pay Audits

• Workflow Enhancements – improve EMR workflows to handle post-pay audits, create job aids and training for internal staff and outsourcing partners to reduce retractions with timely responses
• Post-Pay Audit Communication – creation of dedicated email and team for requests from post-pay audits to accelerate processing of their requests for additional documentation and provide direct communication pathway

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Claim Routing Modifications

• ‍Epic ALT Payor Logic – implement claim routing modifications through ALT payor logic for behavioral health claims or to align with medical group division of financial responsibility to direct claims to appropriate entity at time of billing