On-demand webinar
Denial prevention: From admission to post-discharge and beyond
Discover how to prevent denials — from pre-claim to appeals and automation — with expert insights across the care continuum.
0:09
Hello, everyone, and thank you for joining today's webinar Denial Prevention from Admission to Post Discharge and Beyond.
0:16
My name is Heather Vollmer with Optum and I will be your host today.
0:20
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1:06
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1:23
And again, our webinar denial prevention from admission to post discharge and beyond.
1:29
I would now like to introduce Kurt.
1:34
Well, thank you, Heather, and hello, everyone and good morning or good afternoon depending on where you are.
1:40
I'm Kurt Hoffensperger.
1:42
I'm an Optum physician and I've been working in the utilization review and clinical documentation at denials areas for a little over 10 years.
1:51
I want to remind everyone, as Heather mentioned, please enter your questions during the presentation and we'll try to answer as many as time allows during our panel discussion.
2:01
At the end of this presentation.
2:03
I'd like to now introduce our panelist speakers for today.
2:07
Doug Clovis is a Senior Director and partner with Optum Advisory Service.
2:12
Janessa Delgado is a Registered nurse and is the Director of Clinical Operations for Optum Physician Advisor Service and Utilization Management Service Doctor.
2:23
David Feinstein is the Senior Medical Director of Optum's concurrent compliance and concurrent denials teams.
2:30
Next, we have Tricia Petticon.
2:32
Trish is a Registered Nurse and is the Director of Nursing Operations for Optim Physician Advisor Service and Utilization Management Service.
2:41
And we're also very pleased to have Doctor Robert Wozniak with us today.
2:45
Rob is the Physician Clinical Relationship Manager with Optim Physician Advisor Service.
2:54
Our speakers are going to be covering a lot of ground today.
2:57
We'll be focusing on status denials and those denials and their prevention is, as we can imagine, a very much an extensive topic.
3:06
We'll hear nursing physician and advisory expert perspectives on many of those facets.
3:12
First, Doug is going to give us an overview on denial prevention and the trends he's seeing across the country.
3:19
Next, Janessa and excuse me, Janessa and Trish, we'll talk about the role of utilization review process and navigating the appeals process.
3:28
Rob and David will give us their physician view and experience with denials and appeals, including the role of the peer-to-peer discussion.
3:37
Rob will also talk about the role of medical staff education and engagement to prevent and appeal denials.
3:44
And we're going to finish today with Doug providing a very interesting perspective on automation and its place in denial mitigation.
3:54
We have a couple of audience poll questions during the presentation today.
3:59
So before we begin, let's see what everyone thinks about where during this lengthy process spanning all the way in the beginning from payer contracting through admission reviews, through peer to peers written appeals and so on.
4:15
Where does everyone think the most effective interventions are going to occur to prevent a final denial and therefore prevent a write off?
4:24
No right or wrong answers, but let's see where in your experience you're getting the best results.
4:30
So let's we'll wait about 15 seconds for everyone to make a choice and see what everyone thinks.
4:52
And let's see what results we've gotten here.
5:04
And I may need some help showing the actual poll results.
5:33
Well, looks like we might have a little technical glitch.
5:36
So as we wait for those results and if we do come up later, we will go ahead and show them.
5:42
But in the interest of time as we have a lot of ground to cover, we will go ahead and move on then.
5:50
So at this point, I'm now going to hand it over to Doug Clovis.
5:54
And Doug, please take it away.
5:59
Thanks, Kurt.
5:59
I appreciate it.
6:00
And you're correct, we've got a lot of ground to cover today, especially as it relates to denials.
6:06
I think coming out of COVID, we saw the payers increase the the focus on, you know, medical necessity denials as well as administrative denials.
6:19
According to the Kaiser Family Foundation, you can see on the left here, 58% of insured adults say they've had experience a problem using their insurance over the past 12 months.
6:30
Now that could be a denied claim, it could be provider network problems, but what we're seeing is a lot of friction not only between the payers and providers, but also impacting the patients directly.
6:43
We're seeing across the country about an average of 10% initial denial rate.
6:49
So one out of every 10 claims are being denied.
6:55
We're seeing in the West that number is about 12 to 14%, so which is even even higher when we look at the overall cost of, you know, appealing the denials and working the denials.
7:10
On average it takes about $43 per claim to to appeal and we're seeing over 50% of the denials being overturned.
7:21
So, you know, as we look at the overall cost of about $20 billion to address the denials across the industry, how much of that could be reduced if we are able to prevent the denials before we ever, you know, have to, to fight them?
7:38
So, you know, those are some of the areas that we're taking a look at.
7:41
You know, as we go through, there's also the difference between the governmental payers and the commercial payers.
7:48
And you can see in the in the middle there where the, the, the more commercial ACA claims are even at a higher initial denial rate and many of the Medicare Advantage, you know, plans, we're seeing a higher denial rate.
8:05
And that's one of the areas that we're trying to really address.
8:08
And how do we, how do we get in front of that?
8:11
And we'll talk more at the end around some of the automation, but the, the team's going to talk more about some of the UN related activities.
8:21
And Janessa and, and Trisha are going to take us through the next couple slides around what we're seeing from AUM perspective and how we've addressed that and, and different tools and techniques to, to drive that.
8:34
So, Janessa, can you take us through the next area around utilization review and the process is there?
8:41
Yeah, you bet.
8:42
Thanks, Doug and hello everyone.
8:45
So, you know, we're going to start with with looking at the utilization review process here as as Doug mentioned and and you know, as we know that the first level review process, this this is really the foundation of utilization management.
9:00
You know, the goal here is, is to look at, you know, your, umm, staffing matching that staff, that staffing model to actual hospital volume.
9:11
We want to make sure that reviews are timely, they're consistent.
9:15
We're not bottlenecking things.
9:17
I mean, this really means looking at patterns and, and admissions.
9:21
What's the payer makes, what's the daily census So we can ensure that we're, you know, really staffing intelligently and proactively and and not reacting think moving towards a true seven day coverage as well for first level reviews, you know, as, as you know, patients don't stop being admitted on weekends and and neither should our review process from AUM perspective.
9:44
I think the shift helps, you know, just ensure we don't fall behind and what we're supporting and that can be length of say that can be revenue integrity.
9:55
We know compliance falls into this.
9:57
So really ensuring that that true seven day coverage is locked in is really key.
10:04
I think the next piece here is, you know, establishing clear productivity standards.
10:11
This this really gives your staff clarity around expectations.
10:15
It allows to measure consistency across umm staff.
10:19
I think it helps identify where process improvements or training might be really needed.
10:26
And then I think finally automation as Doug said, we're, we're going to dig a little bit more into this, but where does automation make sense in the UN process?
10:35
You know, this is not meant to replace those those you are, you are nurses or that clinical judgment, but really to streamline some of those repetitive tasks we see in utilization management, helping with status checks work.
10:49
Q Management in the EMR, you know, routing cases to the, to the reviewers, getting, you know, submissions or clinical information to payers.
11:00
And, and so really we can free up those clinical pieces to focus on, you know, where the higher value reviews are really needed, like moving into the next section here on clinical criteria and escalation path pathways.
11:16
You know, once staffing and workflow are optimized, you know, I think the next major component is ensuring we're applying clinical criteria consistently and appropriately.
11:28
We want to make sure our criteria is aligned with payer requirements, you know, means understanding what's required for status determination by payer, what do they need for a prior auth, what's required for continued stay reviews and any misalignment here leads directly to denial.
11:45
So this piece is absolutely critical.
11:49
Another core expectation here is applying that level of care criteria accurately.
11:54
You know, whether you're using Interpol, MCG or other payer specific guidelines.
11:59
So important to ensure that these decisions are evidence based and and defensible.
12:06
And I think documenting clear referral criteria for second level review.
12:10
So this is really this escalation pathway here to perhaps physician advisors, you know, making sure this referral criteria is clear, it helps staff know exactly what to escalate.
12:23
Begin ensures that those attending providers receive timely guidance.
12:29
This prevents unnecessary delays and patient status decisions and ultimately this supports both compliance and of course efficient throughput.
12:40
The last one here is governance oversight.
12:44
I would say this is really a final component of a strong UR program and that's governance putting an emphasis on consistent physician documentation, tying that to UM and level of care accuracy that provider engagement is essential.
13:00
The medical record must clearly support the patient's full clinical picture.
13:05
I think our role as, as UM, is to collaborate.
13:08
It's to educate, it's to really close those gaps early rather than waiting for that denial and risking things downstream.
13:18
UM, committee, I think plays a pretty key role in here as well.
13:21
It, it, you know, a couple of things.
13:23
We want it to be useful and we want it to be compliant.
13:26
So that means, you know, getting consistent and regular attendance, structuring those attend agendas, making sure that there's actionable insights.
13:36
This committee should really function as a, as a core forum for resolving a system wide issues, not just reviewing metrics, but identifying those key trends, clarifying the criteria that's being used and ensuring that operations and medical staff leadership are aligned.
13:56
If this just gives a, a flavor of the areas, you know, to ensure we have compliance efficient, you know, we're supporting the organization's clinical and financial goals.
14:08
And of course, most importantly, we want to create a smoother experience for our teams and and ultimately for our patients.
14:15
I'm going to hand this over to Tricia.
14:18
She's going to lead us through a little bit more on the appeal side of things.
14:22
So Tricia handing it to you.
14:24
Thanks.
14:25
Thanks, Janessa and good morning.
14:28
Good afternoon to everyone.
14:31
So from my perspective and AUM perspective, denials will occur and our job is to understand the root cause, review the documentation and tell a clear clinical story by writing a well crafted appeal and convince the reviewer to approve.
14:48
This day, we need to understand what's driving the denial and study the trends to create clarity, consistency and accountability to prevent denials and strengthen financial performance while supporting high quality patient care.
15:06
Our approach is simple and consistent.
15:09
We review the denial notification to understand the exact reason for the denial, understand why the payer is pushing back, and review documentation, treatment plan, and hospital course.
15:23
Our goal is really to tell the story, explain why the patient needed the service, connect the dots between the patient's condition, the provider's decision making and the care delivered, and support the appeal with strong evidence based criteria.
15:41
The top denials we see is authorization, medical necessity, and DRG downgrades for authorization.
15:49
The key to preventing these denials is to have accurate insurance at a mission.
15:54
Check read for readmissions to ensure the insurance has not changed.
16:00
Pay special attention to newborn insurance as we see a lot of errors in this area.
16:06
Submit complete clinical documentation and send updates as conditions change.
16:12
Timely notification of admissions and having a strong workflow with cues to track pending or missing authorization and insurance information for medical necessity denials.
16:24
What we see as the main driver is incorrect status, missing or insufficient clinical documentation, or incomplete clinicals that are sent to your payers.
16:34
Copy forward documentation or copying and pasting and copying documentation that's not current for DRG downgrades.
16:44
It's so important that your documentation clearly supports the severity of illness and the treatment intensity.
16:52
There's some key questions to help you when addressing DRG downgrade denials.
16:58
Does the documentation align with the bill, diagnosis and codes?
17:03
Are the treatment plans clearly tied to the patient's severity of illness and intensity of service?
17:09
Is the clinical picture consistent across the record?
17:13
The denial prevention is key to protect your reimbursement, strengthen your operational performance, drive quality of care while keeping our patients in the center of all we do.
17:25
Strong denial prevention starts the moment the patient enters the hospital and continues through discharge.
17:31
Having a robust front end workflow for insurance verification and obtaining authorization is key.
17:38
Having strong analytics to help identify trends and root causes, ongoing education and feedback loops to your teams and being very proactive when monitoring payer behavior and really trying to understand your payer contracts and meeting with your payers regularly to discuss your findings and trends.
18:03
All of these steps will help you build a strong denial prevention strategy.
18:08
But Rob, I would love to really understand your thoughts.
18:12
How do you feel or what have you seen from the hospital's approaches to denials to change over the years?
18:21
All right, thank you, Trish, and hello, everyone.
18:26
So, you know, the biggest change that I have seen here, I would say over my tenure at Optum is when I first started here, I got a sense in speaking to hospital clients that they wanted to lean into inpatient, you know, and, and sort out the denials on the back end.
18:44
Basically be as aggressive as possible and trying to make sure that, you know, they were fighting everything.
18:52
And I think there's been an earnest move away from that.
18:56
I would say there's been an earnest change from reacting to denials to trying your best to try to limit them kind of at the source more or less.
19:06
So you know, the front end process like you were mentioning, you know, verifying insurance coverage, verifying benefits as early as possible, ensuring that the demographics are correct.
19:18
All of these are a fundamental first step, right And certainly are going to cut down on the number of administrative denials that you receive.
19:26
And administrative denials as opposed to clinical denials are still, they're going to make up the lion's share of your overall denial volume, which is is a good news, bad news situation.
19:40
You know, on the one hand, those are usually easier to correct, but on the other hand, the volume obviously can be a drain on resources, right, to have to correct and resubmit them, etcetera.
19:53
Clinical denials.
19:54
And that's really what I'm here to speak about more.
19:57
Clinical denials, on the other hand, they usually revolve around medical necessity and documentation, right?
20:04
These can be more challenging, I know to prevent in the 1st place and also unfortunately more difficult to overturn.
20:13
Even in a best case scenario, you know, one where you're you, you overturn the, you know, at peer-to-peer retrospective appeal, there's still resource need, right?
20:25
You're sending the case to Optum, let's say, to perform the peer-to-peer.
20:29
Well, there's a cost associated with that.
20:31
You're, you're referring it to your internal physician advisor, referring it back to your own, you know, involved attending, you know, that's, that's a resource train.
20:41
And I don't even need to tell you obviously that sometimes you could have the strongest case or a case that you feel is strong and well documented, go through this entire process and still it's successful, it's upheld at the end of the day, you know, And so increased denial volume a lot of times can lead to increased write offs as a result.
21:04
I just have a few general statements here before I'll hand it over to my colleagues for some more specific examples.
21:11
But when I, I mean, it's going to sound simplistic, but when I think of avoiding clinical denials, the first thing I think of is to make sure you're getting the appropriate order on the chart as early in the hospitalization as possible.
21:28
The entire statusing of patients as, as you probably all know, is, is in the purview of the attending physician, right?
21:35
The Medicare benefit policy manual, for instance, says that the decision to admit a patient is a complex medical judgment that can only be made after the physician has considered a number of factors.
21:47
So because ultimately it's the attending that determines status, a thorough understanding of status by attendings and however your facility decides to go about this is so certainly up to you.
22:03
But I think it's vital that attendings, if they're in charge of status, have at least a working knowledge of what goes into status and whether, you know, sometimes we here at Opus will give, you know, physician education sessions around status.
22:20
I know you know, many of our hospitals also have internal P as and perhaps through regulars, regular education sessions there or even, and I think it can be quite valuable or even on on an ad hoc basis, you know, case by case.
22:36
Sometimes if you see something to come back to the attending and kind of re educate on the spot.
22:42
But the bottom line is your hospital or your, your, your system should have a framework where you're feeding back information and education to attendings.
22:54
First level review products, as we all know, aren't dispositive in terms of status, right?
22:59
There are known challenges with commercial first level review products.
23:03
You know, some are, some have some diagnostic specific in our inaccuracies.
23:08
You know, sometimes they're especially early in the hospitalization time, expectations can be off.
23:14
And as we all know, you know, quite commonly they're somewhat rigid, right, Failing to account for the, you know, the the actual complexity of the patient you're treating, which you know, is precisely the lane where physician advisors come in.
23:33
So at least as far as it pertains to patients held to the 2 midnight rule and probably for most of most of the hospitals now with the 42 O one and the applicability of the 2 midnight rule to Medicare Advantage plans, that's probably going to describe the majority or at least plurality of your hospitalized or bedded hospitalized patients.
23:58
So I think it's vital that attendings now at least have a working familiarity with some of the nuances of the 2 midnight rule.
24:08
I'm not saying that they need to be, you know, they need to be all miniature physician advisors, you know, with the deep knowledge of this.
24:18
But if there were a few things that I would want my attendings to know.
24:22
And I, you know, sometimes when we give education, I like to keep it somewhat simple because if you get too detailed, sometimes you lose the, the forest from the trees, so to speak.
24:34
You know, there's so much information, there's so much detail, there's so much complexity to it that, you know, attendings come away and really they have, they come away with things that maybe more than they needed to know.
24:49
What I would want my attendings to know is in terms of at least the 2 midnight rule, you know that inpatient medical necessity is a combination, right, of medical necessity.
25:01
If you're choosing an inpatient status, it's a combination of inpatient medical necessity with the regulatory overlay of time.
25:10
I would want my attendings to understand exactly the benchmark so that they know that that patient that's presenting say 10/30, 11:00 PM at the in, in the ERCOPD exacerbation, you may be approaching differently in terms of status than one that arrives an hour and 90 minutes after midnight.
25:31
And I think really attendings, especially our nocturnist need to be knowledgeable about when the when the clock starts, when start of service is for these patients in order to appropriately apply the benchmark.
25:47
I think equally crucial is understanding, you know, which midnights basically don't count, which are, you know, convenience care, custodial care, delays in care, especially the latter.
26:01
I think some, maybe the two former, you know, most physicians can kind of grasp, but say, you know, you're a hospitalist on a Saturday night and you're bringing a patient for chest pain and you only, do you know, you only do stress tests on a Monday.
26:17
You know, if there's no other intercurrent medical necessity for that Sunday night when you're determining what the appropriate status is on that Saturday, I want attendings at least in the back of their mind to understand, well, that may be a delay in the provision of care and maybe that midnight would not count towards the benchmark.
26:37
I think lastly, if there's so many exceptions right to the 2 midnight rule, and I'm sure many of us on the call are familiar, you know, with all of them back and forth.
26:47
For my high volume attendings, the ones who are admitting patients and discharging patients all the time, I want them if they are discharging a patient prior to the second midnight being crossed to at least have a bell go off on in their head that we need.
27:04
I need to be documenting, you know, if it applies, of course, but I need to be documenting that.
27:10
I expected 2 midnights of care.
27:12
It turned out not to be the case.
27:14
There was a faster than anticipated recovery for XY and Z reasons.
27:20
You know, and I, I think that a lot of times just kind of closing the loop on those charts at the end can really help the defensibility of some of these cases.
27:30
Obviously once the inpatient order is written, timely verification of the appropriateness of the inpatient orders is really paramount to a well functioning UR process.
27:39
I think Trish had mentioned, you know, if there are gaps in coverage, you know, weekends or sometimes nights, you know, whether or not you might even consider it, you know, reaching out for assistance during those times where you may be a little bit short staffed.
27:56
And what is your clearly defined process, right, for utilization review?
28:00
Are you reviewing all cases that occupy a hospital bed?
28:03
Only inpatients, maybe only observation patients past 1 midnight?
28:08
Are you using commercial screen for every case?
28:12
And those that fail, are you sending all of them to a physician advisor?
28:17
Are you only sending some of them even?
28:19
Are you utilizing or leaning into AI to some degree, which I think Doug will speak to towards the end.
28:25
But are you leaning on these tools as well to help determine the right cases to send for second level review?
28:33
Because at the end of the day, those second level review, those second level reviews rather can, you know, kind of give you a second bite of the apple, so to speak to see if inpatient is appropriate.
28:46
If you have a robust upfront, you are process in concert with good communication with attendings who are invested in this process of appropriate status and they're focused on good documentation, I think you can feel confident that your inpatient bills that you're submitting are going to be highly defensible.
29:08
And in a best case scenario, you're doing two things simultaneously, right?
29:12
You're limiting your denials and you're giving yourself the best plans for overturning any that do come through.
29:19
But I don't want to lose sight of the fact that if a denial is inappropriate, it's gone through your standard UR process with or without position, physician advisor, but involvement.
29:28
It's important to stand up for yourself, right?
29:31
To draw a line in the stand, you know, empower case management and get paid for the services you're you're providing.
29:39
It may be a truism and it probably used to drive the notion of, you know, let's just press into inpatient and deal with all the denials on the back end.
29:49
But it's a truism.
29:50
It's true that, you know, the more you appeal, the more you're going to overturn.
29:54
But obviously the legwork of needing to do all of these denials, perform all of them, especially if it's possible that better physician documentation might have served to better support the inpatient and possibly avoid a denial, you know, well, I that's in the interest of, you know, of you of the provider as well as the attendings as well as your UR staff.
30:18
So let me just finish with a few quick words on physician documentation.
30:23
And you know, all of the data and elements considered by the attending physician, right?
30:29
They, they, you know what's in the HPI, the, the, the review of systems, the labs, imaging, et cetera.
30:35
All of that should be synthesized into an assessment and plan that has, you know, that has a an eye towards acuity and risk with a forward-looking plan of care and a length of stay expectation tied to those specific clinical factors that are informing that expectation.
30:56
And it shouldn't just be in the HPII.
30:58
Think a lot of times you've probably heard everything I've said many times in the past.
31:03
I think what's really crucial is this next day progress note.
31:07
Sometimes you see a reasonable expectation in the HPI of two midnights of care, right or something along those lines.
31:16
And then the next day, you know, COPD patient, for instance, then the next day they say, you know, in the progress, no patient is is off oxygen doing well.
31:26
And you look at the assessment and plan, it says continue IV steroids, continue IV antibiotics, you know, maybe repeat lab work or something like that.
31:35
And you're left looking at this case as well.
31:38
What was precluding discharge that day, right?
31:41
Like what what is the arc of care of this patient?
31:45
What happens so often in these progress notes is that physicians document to stability where, you know, payers obviously are looking for documentation towards instability.
31:57
And I think that that's a real challenge in the progress notes.
32:01
And when you're looking at these cases, and quite frankly, it's why copying and pasting is the absolute enemy of good documentation because you know, you look at these cases and you see the same exact assessment and plan day 2, day three, and you're giving a toehold for a denial by the insurance company because there's no clear story on what you're waiting on.
32:25
I know that we're at the cusp of AI having a, a big role in avoiding denials.
32:31
We already are there to some extent, but the role of attending documentation and a strong you are, you know you are process appropriate application of screening tools, involvement of physician advisors.
32:44
I think all of this will continue to be key.
32:47
I think that AI is going to be additive to this process to attempting to move forward to decrease the friction between payers and providers, ensuring that hospitals get appropriately reimbursed for the care that they are providing.
33:04
But I don't want to drone on too long, David say we do get a denial here.
33:11
It's gone through this robust upfront process that we just spoke about.
33:16
Can you kind of lead us to what's next?
33:19
Yeah, So let's give you a little bit about my background first.
33:24
So I've been with Optum for 18 years now.
33:29
The last half of that time I've been managing and running the concurrent denials team.
33:36
Before that I was on the current compliance and before that I was a medical director for a basically a small independent positions association that worked closely with the insurers.
33:50
So that puts me in a kind of a unique position where I've seen both sides of this whole process.
33:55
And I'll just say that I'd rather be on this side than being on the insurer's side of things.
33:59
But having had that experience, I could tell you it's very interesting what I what I have seen and and what we're seeing now.
34:09
But before I get into that more interesting stuff, I'm just going to give you a brief background.
34:14
So this is all kind of nuts and bolts.
34:16
When you do get a denial, there's there are various steps that we go through to get the denial process and get to the peer-to-peer discussion portion.
34:26
First of all, you know the client will the hostile client will send us a case, we'll create the actual denial.
34:32
We'll set up the peer-to-peer discussion.
34:34
We have a team that does all of these things.
34:36
We'll gather and process the clinical data and then eventually we will have the discussion with the actual medical director.
34:43
So that's pretty basic.
34:44
And like I said, we have teams that do that.
34:46
The administrative team will actually call the payers, set up the actual verbal discussion via the telephone.
34:56
We have a nurse team that collates and organizes the clinical data.
34:59
And then we have a group of physicians, currently have about 20 physicians that work every day and all they do is peer-to-peer discussions with the physicians, the medical directors for the pairs.
35:11
So having gotten that out of the way, that's just like I said, that's just the nuts and bolts.
35:15
But what's interesting is when we get to the data, so there are two, I'm going to kind of split this into two things.
35:22
The first is the commercial plans.
35:24
And you notice that I left the commercial plans blank.
35:27
All right.
35:28
Why did I leave the commercial plans blank?
35:30
I didn't give any data really because the data is all over the chart.
35:34
If you look at the Kaiser Family Foundation data from 2023, the denial rates per, you know, various pairs is incredibly, it has an incredibly widespread.
35:49
So Avera Health has basically a denial rate of 1%, whereas Buckeye Community Health Plan has a denial rate of 40%.
35:58
Blue Cross Blue Shield of Alabama 35, United Healthcare 33, Healthcare Service Corps 29.
36:03
It goes, it's, it's wide.
36:06
And the question is why?
36:08
Well, we're not exactly sure to be honest with you.
36:12
We're not sure why this denial rates are so, so, you know, widely varied.
36:17
Some of it does have to do with their markets, the patients that they are signing up as part of their insurance, but it is, it is incredibly wide.
36:27
It's kind of the Wild West to a certain degree.
36:30
But don't let that discourage you.
36:33
The bottom line is that despite the the massive variation in denials, what we do find is that our when we do peer to peers and and discuss things with the medical directors, we see a lot of interesting things.
36:47
And this is where, you know, having good relationships and long term relationships is really helpful.
36:54
We see such things as medical directors being a really good mood and wanting to overturn things.
37:00
We find that when a medical director speaks with the same physician advisor, one of our doctors, time and time again, they develop a relationship.
37:08
And as a result, the medical director is less willing to uphold a denial because they develop a in a sense of a relationship with the physician advisor on our side, it becomes much more collegial.
37:21
And that is a huge thing for getting overturned.
37:25
Despite the fact that you think, well, you know, medical directors, you know, they're not, they're not really looking at things from, from such a subjective point of view.
37:34
The fact of the matter is they do.
37:36
And we find that when that relationship develops, the medical directors are actually looking for ways to overturn the denials.
37:43
And they will ask us questions over and over.
37:45
We see this day in and day out.
37:47
We've seen it for 10 years.
37:49
You have a discussion with somebody, you know, they will ask you, well, did the patient have this problem?
37:55
Was the patient receiving this?
37:57
How bad was this?
37:58
And we find that information, we give it to him, The medical director will overturn the denial.
38:02
So these kind of relationships are crucial to helping with the overturn rates that we find in our peer-to-peer discussions.
38:13
What are the reasons that they will deny things?
38:15
It's everything that Doctor Wozniak and my other colleagues have said.
38:18
It's often due to a lack of medical necessity, lack of prior office authorization, and sometimes there's administrative errors, right?
38:26
Those are all things that, you know, are very common that lead to denials.
38:31
So again, with a commercial plans, it's kind of the Wild West in terms of their denial rights.
38:40
So let's go to the Medicare Advantage plans.
38:45
Medicare Advantage plans like to deny a lot.
38:51
In fact, as you see from the data, they were not compliant with CMS42O1-F.
38:56
What is 42 dot O1-F?
38:58
That is the final.
38:59
That is the 2 midnight rule.
39:00
That's the final.
39:01
That's the F stands for 42 O1 basically talks about the the 2 midnight rule and you can see from the slide it's 86% of the time.
39:11
And again, why do they do that?
39:13
Well, they feel that patients have a lack of medical necessity and there's one little thing that helps them do that.
39:22
It's not that they're necessarily not compliant with that rule, it's the fact that they use a loophole that is basically from the Social Security Act 1862.
39:34
And what 1862 says is that Medicare does not have to pay for a service when that service can be provided in a lower cost setting.
39:43
Well, obviously the managed care companies are going to basically seize upon that, and that's what they use.
39:50
They say that this doesn't meet their criteria for medical necessity.
39:53
Therefore, we are going to uphold this denial, which is all fine and good.
39:58
Now I know as hospital administrators and such.
40:03
You want money upfront, you have bills to pay, you have a certain basically flow of cash for for lack of a better term, it would be nice to get the money upfront and not have to wait six months to get that.
40:17
However, what's what's fortunate is that there is an overturn rate and this is across the, this is across the board with our medical directors here, with the information we see, with our even our competitors nationwide data, the overturn rates for these Medicare Advantage plans when they basically deny originally with the peer-to-peer discussion, we have overturn rates between 50 and 60%, which is great.
40:43
And of those, there's another percentage that will go to a written appeal, which is a different division than mine and we will get another small percent of overturns.
40:54
So what's the bottom line for that?
40:56
Don't leave money on the table.
40:58
If you have a patient that has true risk and true medical necessity, always contest the denial.
41:04
It is worth it for your bottom line.
41:06
Don't leave money on the table.
41:08
There's nothing wrong with it if you look at it from a purely return on investment point of view.
41:14
If you do say you send US10 denials and we only get one overturn, that is definitely going to be a huge return on investment for you.
41:26
So my advice, make sure the patients have medical necessity contested denials, don't leave money on the table.
41:35
So now the question I would go back, my colleague, Dr.
41:38
Woznick, what thoughts do you have on how hospitals can help their physicians get the status correct?
41:45
Because that's a huge part of this.
41:51
OK.
41:52
So thank you, David.
41:55
Yes, you know, like I kind of covered I think much of what I wanted to say previously, but you know, clinical denials revolve largely around documentation issues, right.
42:09
It is my opinion that I think hospitals and and healthcare systems are very good at identifying root causes for denials.
42:19
A lot of times you know, they're looking at data, they're looking at payer specific behavior.
42:24
I think that they, I think there's such an interest in keeping your finger on the loop of what's happening with denials that there is a lot of institutional knowledge.
42:34
But I think, I think leveraging that knowledge back to the attending physicians for cases which were denied regardless of outcome.
42:43
I think sometimes we only look at the ones that were, you know, that were upheld, but also the ones that were overturned and root causes for why can be, can we can be crucial.
42:54
I, you know, I mentioned before that, you know, physician education is really beneficial.
43:02
I think I might add to it here that it can speak loudly to to physicians, to attendings if they are aware that you're monitoring denial rates on an ongoing basis specific to physicians, right, Specific to that physician comparing each physician's denial rates versus one another.
43:24
Isn't it not so much that you want to be saying, well, you're not doing well or you're doing well, but more because it helps drive better engagement and sometimes compel in a best case scenario where maybe there needs to be some, you know, some changes, you know, So I think that it helps drive engagement if you, if physicians are aware that you are monitoring these behaviors and also who doesn't like a KPI?
43:51
You know, it gives you a measurable performance indicator moving forward to see how effective your education strategy has been and with whom it's resonating, etcetera.
44:02
So, you know, overall, I, I think that I think that the one area where many hospitals might be able to do better is getting that physician education back to the physicians about the, you know, the, the status and, and what had happened in that case.
44:19
So I won't spend too much time here because I know that we're somewhat running well, we're running on time, but I don't want to, I don't want to certainly run over here.
44:30
And I see that there are a lot of questions.
44:32
So I do want to leave ample time for that.
44:35
I am going to take a take a risk here.
44:41
I know it didn't work for Kurt before, but we have a yes, no poll question.
44:46
Are you using any AI or automation from a denial prevention analytics perspective?
44:53
So are you using AI essentially as a, as a denial prevention tool?
45:00
I'll just give 15 or so seconds here to see if the answers come up and then and then we will see together if we can view the results.
45:11
But I'm pretty hopeful here.
45:13
And actually this sets the stage, I should say for, for Doug's for, for the end of the presentation about claim denial protection and automation.
45:25
So I think we have a reasonable quorum here.
45:30
Excellent response rates everyone.
45:32
I am impressed.
45:34
So Doug, I think that this sets the stage well for you.
45:40
You know, it looks like the vast majority here are actually not yet using automation or AI as a denial prevention tool.
45:50
Something tells me if we ask the same group five years from now if they are, the answer may be switched.
45:57
But why don't you take it away, Doug, and, and we could move, move right on to you.
46:04
Well, Rob, I appreciate that.
46:05
And I, I would just shorten that time frame, probably down to two years and we'll see.
46:09
It's probably switch, you know, the use of automation and, and AI is dramatically changing as we go and it's, it's exponential growth as we go through there.
46:21
But you know, just listening to the, the panel, it's been a great discussion so far.
46:25
And Trish talked about, you know, the authorization at the time of admission and getting that right.
46:31
That is so critical, you know, the steps in there.
46:34
And then you know, Rob, you know, you talked about the physician documentation.
46:38
We always talk about how critical that is.
46:41
But really as as you appeal denials, they're going to go back to the documentation.
46:46
Those are things you just have to do every day, day in and day out and really get that correct.
46:52
So interesting to see, you know, only about seven, 7% of the organizations are using automation or AI from a denial prevention perspective.
47:03
But we're seeing some of the leading organizations really move into utilizing the technology.
47:10
Doesn't mean you have to go all in on AI.
47:14
There's a lot of automation in your EMR that you could use today.
47:17
There's some what we call RPA, robotic process automation and there's machine learning all the way up to AI.
47:26
So there's different parts that you need to look at and you know, as we work with organizations, we're really looking at what's the overall strategy to be successful.
47:35
So, you know, you don't want to just jump in and say, let's automate this process.
47:40
Well, with what tool with, you know, you know, what process are we going to use human in the loop?
47:46
You really have to take a look at all of those different processes and really it starts with a clear vision.
47:52
What do I want to automate and how do I want to automate it?
47:56
And what's the result that I'm expecting?
47:59
Is it going to replace a job function?
48:03
Is it going to be a part of someone's job?
48:06
Just what are we looking at automating?
48:09
And then also, do I have a good process today?
48:13
You don't want to automate a bad process because you're just going to have a faster bad process.
48:18
So that's not what you want to do.
48:21
You also wanted to, you know, look at the tools you don't want to use, you know, a AI to use a very simplistic, you know, activity that RPA or, or just your EHR can do.
48:33
Don't look at fragmentation.
48:36
You know, what this means is you don't take a look at the process and just use AI or automation just for parts of it.
48:45
Because at the end of the day, you're going to have automation on some of it, but you're not going to reduce the, the effort from the from the human.
48:53
So you're really not gaining anything.
48:56
And the last 1 is probably the most important.
48:59
Don't assume every automation will have an ROYI know we're we're looking to say what's the return on investment for all of these.
49:06
And you know, sometimes you're just not going to get a return on investment in some and that may be OK as long as you go into it looking at it from that perspective.
49:18
So we look at automation, you know, we look at the continuum and how, how do we use automation to help from a denial prediction perspective and quite honestly, from a prevention all the way from the far left.
49:34
Organizations are using the automation and tools that are built within your EMR.
49:42
So a lot of the, the claim edits just don't bypass them.
49:48
You know, they're, they're there to help the billers, you know, correct the claims before they go out.
49:54
It's amazing how many times we see claims go out and get a denial coming back for something that was in the claim scrubber, but someone just bypassed it.
50:02
So, you know, all the LCD and NCD edits, just we need to correct those before they go out.
50:11
The second one which I'm going to talk a little bit more about is the prebuilt prediction and organizations are starting to use AI and automation to really take a data set of their bills and EO BS run that through an AI to agent to really take a look at identifying trends of denials.
50:37
So then you can take your bills that are created and identify some of those trends where say last 10 times that I billed Medicaid for this, a claim that looked very similar to this.
50:54
I got a denial for X.
50:57
Let's correct that before it goes out.
51:00
And then I won't get a denial and I won't spend that $43 per claim that we talked about earlier.
51:07
So that's that's another area.
51:09
And then from a post denial, like the team was talking about how do I get the most out of that?
51:16
Who do I appeal?
51:17
When do I appeal?
51:18
And are there, is there automation that can help with those appeals?
51:23
You know, the agentic, you know, AI that we're working with across the board on some of this stuff.
51:29
And then for this area, we're really looking at generative AI.
51:33
How do we generate that appeal letter based upon success that we've had in the past for this condition and this payer?
51:43
It really needs to get down to that level because different payers look for different components when they're reviewing the appeals and you can you know what's successful and what's not.
51:58
So we've built models to create appeal letters based upon the the payer and the condition that's being denied.
52:08
And then you have that, then you still have the human in the loop or you have a physician or or clinician review that make sure it's appropriate for it goes out the door.
52:19
And we've seen a lot of success around that and reducing the level of effort to the to appeal those.
52:26
But that helps you get to get the the information correct the first time.
52:34
The next slide really talks about a little bit of it's, it's something that we've got, we've worked with organizations around this is really setting up that denial prediction process and what it looks like from a Vizio flow chart.
52:48
It's really how do I determine the high volume or high dollar denials and what do I need to go through?
52:56
And we talked a little bit about on the last slide, really applying an AI model to your 830 fives, which is your EO BS and your 830 sevens, which are your bills to develop the denial patterns.
53:09
You really take about a year's worth of data, ingest that and you know how the AI look for the patterns.
53:16
And then as you bill clients bill create bills on a regular basis, you run this through the model and, and identify potential opportunities for denials.
53:30
So when you do that, you have two options.
53:33
You can either create a, an automation to correct that or you can Kick It Out to a human to correct before it goes out the door.
53:41
And then that way you can actually help reduce the overall denials process.
53:47
That's been a very successful program that we've we've looked at and helped reduce denials.
53:54
And really the more we can prevent the denials, it's going to reduce our administrative spend and also quite honestly help with the patients as well.
54:07
So they don't get the denial.
54:08
They don't have the frustration of calling the providers and the payers and trying to work through that.
54:15
Let's to get the patient out of the middle.
54:17
Let's work through those get get the bill out the door correct the first time and then that way we can you have a much more efficient process reduce that 20 million, $20 billion of spend that we are doing annually to to fight the denials.
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