Tackling Denials and Prior Authorizations for Revenue Cycle Success

Carla, an accomplished Director of Revenue Cycle, possesses extensive and advancing expertise in managing revenue cycles and financial stewardship in the healthcare sector. She excels in working together with all individuals within the healthcare organization to successfully attain business and financial goals. She is also skilled in optimizing operations, improving productivity, introducing innovative processes, and implementing technological advancements.

Please tell us about the journey that you've had so far and your roles and responsibilities at Bay Area Hospital.

Throughout my career, I have gradually progressed from being a float pool receptionist to holding positions in various departments, including dental, and ultimately reaching a management role where I currently stand. It has been an enjoyable journey, and my current responsibilities encompass overseeing the entire revenue cycle process. This includes managing tasks ranging from patient registration and scheduling prior authorizations to handling CDM, revenue integrity, and back-end patient accounting.

What are some of the major challenges in the revenue cycle management space?

The main challenge is dealing with a significant number of overall denials, both clinically and financially. Currently, there has been a noticeable increase in the volume of denials, particularly related to prior authorization, concurrent review, and medical necessity.

Another potential issue could be regarding prior authorization, where a patient undergoes surgery for one procedure but ends up receiving another. If this discrepancy is not promptly reported within the designated 24 or 48-hour timeframe, it can lead to a denial of coverage due to lack of prior authorization. This situation can pose challenges, particularly when such incidents occur on weekends or outside regular business hours.

The CO-45 is another type of authorization that is frequently encountered and requires thorough investigation. Different insurance companies may have varying reporting methods for this type of authorization. However, it typically results in a secondary denial, necessitating further investigation. Consequently, my team and I often spend more time contacting the insurance company to determine the exact reason for the denial. The reason may be simple but it often consumes a significant amount of our time and involves dealing with numerous issues not accounted for in the payer's policy.

What are recent trends that have evolved to help tackle these pain points?

I have a revenue cycle analyst who performs monthly trend analysis. Once completed, I distribute the analysis results to various departments I have. We have a clinical review team responsible for examining denials and drafting appeals if necessary. Our goal is to resolve these denials within 30 to 60 days of initial discovery.

Is there a project initiative that you've been part of recently and have implemented one or couple of these trends to make that successful?

One important aspect we are focusing on is price transparency. We are carefully examining our CDM to ensure our prices align with market standards. It is crucial to strike a balance between not overcharging customers and not undervaluing our services. My revenue integrity team and I have been dedicated to investigating the CDM to identify opportunities for implementing these initiatives. 

How do you see the revenue cycle management industry evolve over the next few years?

The industry is moving towards AI, however, it is important to recognize that a human element will continue to be necessary. It is because though AI offers significant benefits and can assist with various challenges, it is undeniable that human involvement remains essential. Since humans are responsible for programming these systems, there will always be potential scenarios or uncertainties that the AI might encounter. Therefore, it is crucial to have someone available on the backend who can effectively assist in handling such situations and managing the associated data.

Any specific piece of advice that you'd like to share with your fellow peers or other industry leaders?

One of the main points I would emphasize is the importance of education. To me, education and the application of knowledge are sources of power. Through my own experience, I have recognized that educating our clinical colleagues as revenue cycle professionals has proven to be highly effective in obtaining the necessary information for revenue generation.