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Best of 2023 – Are You in Denial About Healthcare Denials [PODCAST]

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In this Best of 2023 episode, Gloryanne Bryant, Consultant, Speaker & Educator, discusses healthcare denials, trends, key findings, actionable steps, and more.

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Highlights of this Best of 2023 episode include:

  • Hospital inpatient denials
  • Clinical denials
  • Writing appeals
  • Specific data elements for tracking denials
  • Key actionable steps to decrease denials

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Gloryanne Bryant. She has over 40 years of experience in HIM coding, CDI, and compliance. Gloryanne is the past president and director of CHIA, having been an HIM volunteer on local, state, and national levels and served on and led many CHIA, AHIMA, HFMA, and ACDIS work groups and committees. She is a sought-after adviser, mentor, national educator, speaker, and author on clinical coding compliance and ethics, reimbursement, CDI, physician querying, coding regulations, and denials. Over the past four years, she was an expert witness and consultant for clinical coding, documentation, charging, denials, and MS-DRGs. Currently, she works part time as an independent HIM coding and CDI compliance consultant. In this episode, Gloryanne will discuss healthcare denials, trends, key findings, actionable steps, and more. Thank you for joining us to discuss this very important topic, Gloryanne.

Gloryanne Bryant: Great to be here with you all today.

Kelly: Well, great. Let’s jump in, shall we? Gloryanne, you’ve had some experience working hospital inpatient denials in the recent past. Can you share a few things that you’re seeing?

Gloryanne: Yes, happy to do that. Over the past year, I’ve seen denials kind of increase. And I think this partially is due to the public health emergency that we had, with everything kind of changing our world, and we put a kind of hold or freeze – some people called it a freeze – on these types of activities, but that has eased up now. And payer reviews have increased, and they are something that we have to be right on top of. I also think we are seeing a greater use of data analytics via using claim data elements to identify “potential,” and I emphasize that. It’s in potential errors or issues with a claim being paid for a particular diagnosis code or even procedure code. And that could be clinical validity and coding accuracy. Thus, I’m seeing these denials increase in a big way for hospital inpatient around the validity of the clinical diagnosis and the accuracy of the ICD-10-PCS code itself. So we’re looking at those two areas that kind of overlap the clinical documentation and equity area and the coding area as well.

Kelly: Very interesting. And when it comes to “clinical denials,” what is the key finding or rationale for the denial?

Gloryanne: There can be a variety of clinical aspects to the clinical denial or the rationale from the payer. Now, having reviewed over 300 inpatient care denials, a variety of payers, there are some trends and patterns that I’ve seen regarding their findings or their rationale when they write back to the hospital. And the first and foremost that I see is that a diagnosis, condition, is documented in the medical record, but then it is not supported by clinical indicators, clinical supporting signs and symptoms from the patient or by industry-known clinical indications of that condition or disease. And we have published information on these clinical conditions that come from professional medical societies’ associations, but it’s also published in other clinical literature. So, they are using those types of rationales to identify these types of clinical denials. And what I’m seeing from my trending that I’ve been doing on these cases is that we do see some conditions’ diagnosis pop up repeatedly.

And I know that most of you out there maybe in the industry probably are aware that sepsis is one of those that continues to pop up on the denial list. And it can circle around the criteria that has been published on sepsis diagnosing that could be a sepsis-2 criteria that the hospital or organization is following and a sepsis-3 clinical criteria that the payer is utilizing. Another one is acute respiratory failure or acute and chronic respiratory failure, clinical validity, acute kidney injury, acute renal failure – that’s kind of a two-prong terminology that we use – and then encephalopathy diagnosis and malnutrition diagnosis. Tracking all of these types of diagnoses in your log for these types of denials is going to be really, really important. And I call it the best practice in healthcare industry, tracking your denials, tracking the clinical denials in detail, tracking the coding denials in detail. So, when it comes to these clinical denials, those are some things that pop out. There’s lots of others, but for this audience today, those are some of the things that I’m seeing.

Kelly: That’s great, very valuable. What are the key learnings we can take from writing appeals?

Gloryanne: Yeah. And so, as I mentioned, denials, well, with that review of over 300 denials, there are several that we have had written appeals for. Not every denial will warrant an appeal, unfortunately, because there are some issues with the clinical documentation, the clinical indicator. As I stated above, in the situations of using these clinical indicators, clinical indications, clinical evidence, it’s not in the health record. It isn’t in that encounter record for that inpatient stay, but the provider has documented a particular diagnosis. It got coded. And then it was submitted on the claim. So, when it comes to the appeal for that, your organization or hospital should follow a specific formal format to all your appeal letters. And it’s important if you have multiple people writing appeals or helping write appeals, that everybody’s on board, everybody’s using a consistent format and style.

Now, the content changes with each patient, but you’re going to include patient demographics. They come from the appeal, the denied letter. And you want to provide that back, so we’re all on the same page with the patient. We know which patient it is, which date of service, etc., so a list of demographics. And I like that at the beginning of your appeal letter. Next, what I like to see is that you outline briefly what is being denied. Is it both the principal diagnosis and the secondary? Is it just the secondary? What is the element that’s being denied? Next, a brief summary in your appeal of the case. Now, make this brief because some cases can go on and on, and you want to make it a paragraph kind of length. So don’t make it too long, but state some basic facts. And then, also, identify, is it being a CC, MCC, or an HCC APR-DRG that is being impacted, and that you believe that particular CC, MCC, etc., is still valid. And here is why you think it’s valid.

So, next, you’re going to list the different dates and times and location in the medical record, where that supporting documentation for that CC, MCC, etc., is in the health record. I like to sometimes see even a copy/paste or a quote from the actual narrative that the provider stated in the records, so your payer sees that as part of your justification. They don’t have to dig around for it. Here it is right in the appeal. So copy/paste that quote, actually, that narrative into that appeal letter. I would say you’re going to have about maybe three, four, five, six actual places in the record that supports your position. Next to see is your final kind of statement that comes out and says, “Okay. Here’s the facts above. Here’s what we believe happened. And here’s why we believe our diagnosis is still valid,” closing all of your appeals with the name, credentials, email contact for the individual writing the appeal. But there are two other pieces that are helpful in writing these appeal letters. I like to see your references. So, underneath the signature name and title, put a reference, and reference where you’re basing your facts. Is it based upon AHA Coding Clinic, the official guidelines for coding and reporting? Is it a CDC information, the National Institute of health, NIH? Published information, it could be that professional association or society clinical literature. So have listed references. And they may be two, three, four different references that support your position.

Well, you’re not done yet. Another thing that I saw in some appeals, that I kind of like this, is that you list exhibits. Exhibits are what was actually in the medical record. So this is a copy/paste type scenario where you insert into your letter a specific portion of the medical record documentation. And you kind of highlight. You can crop it and highlight or even point to the part of the documentation, medical record where the payer should focus. This is where you’re getting that information from. Now, in your narrative that was above, you can put in brackets, “See Exhibit One. See Exhibit Two.” And I’ve seen some of these appeals with usually one, two, or three exhibits. I’ve seen them go as many as four exhibits. It does make your appeal letter a lot longer, but if there’s really strong clinical validation for your position, let’s put it there in front of the payer, so you’ve got it listed above in your narrative. It could have been a progress note, a particular day and time. Now, below in your exhibit, you have that specific progress note. Screenshot and insert it. So, I think this would be a way for you to really learn about your appeals, making sure consistency, continuity.

Now, having said all of that, [laughter] I do want to mention another lesson learned that I’ve seen for our hospitals is that we write our appeal, and it gets denied a second time. That does happen. Now, if you still believe that your position is valid or why you submitted that diagnosis, and you want it to remain or procedure code remain, then write a second appeal. Now, the logic and learning behind that is a second appeal most often will have a different set of eyes at the payer side that is reviewing that. And it is good to have a second set of [laughter] eyes look at your appeal. And so, sometimes, this is helpful to overturn the denial. And it’s just a little lesson learned that I think might be helpful to the audience.

Kelly: Wow, that’s a lot of great information, Gloryanne. Thanks so much. And you stated that tracking denials is important. What are some of the specific data elements that you think should be captured?

Gloryanne: Yeah. So, this tracking is really important. And as I mentioned, you might have a tracking type of software for these. And I think those are a wonderful tool to have. You may have not had the luxury of having a software program that you purchase to help with this. So, you can use an Excel spreadsheet. My side, I know that my hospital has a tracking log, and they’re using a software program, but me, as the reviewer and coordinator for these denials and appeals, I like to see certain things, also. So, there’s the common data elements that are really important to capture, obviously, the demographics, like the account number, medical record number, the patient admit and discharge date, the patient’s name. It may be just the last name. I find that pretty helpful, just the last name. I also track, of course, facility name, but the payer, the payer that the patient originally had as their primary payer. Now, this may be Aetna. It may be Blue Cross Blue Shield. It may be UnitedHealthcare. So I’d list that and track that. The next one that I find is interesting, and this was a lesson learned on tracking this data, is the payer payment methodology. I have a column where I insert whether this is being paid on a managed Medicaid. Is it being paid on a managed Medicare? Is it being paid on APR-DRGs? Is it being paid on MS-DRGs for this inpatient stay? And that’s kind of important, especially when we look at APR-DRGs, because our process for payment on those is that for every APR-DRG, you can have four levels for severity of illness and four for risk of mortality. And often, it’s the severity of illness that’s being denied, a particular diagnosis that has increased the severity of illness, that they would like taken away. So, there’s a lower severity of illness in that payer. So that’s a good one to track and trend.

Also, the specific APR-DRG, if your methodology tells you it is APR-DRGs, which one is it in the title? It could be an MS-DRG, the number and the title, the admitting MD, the discharging MD. And this is interesting. I found some differences between admitting physicians, of course, documentation when they’re first admitted as an inpatient and then what the discharging physician will say, if it’s a different physician, which quite often it is. So that’s an important one to trend…the physician because you might end up seeing which payer will identify conflicting documentation between that MD and that discharging physician. And that can be something that identifies educational opportunities down the road for your providers. We would also want to identify the amount being denied, the dollar amount, which most payers put on their denial note letter, but on some of them that I’ve seen, they didn’t have it. I like to see, also, that we track if it was reviewed by CDI, your clinical documentation. So, sometimes, these denials are one and two days’ length of stays, and maybe your CDI did not have a chance to review that and clarify documentation. So, I like to track whether CDI saw the patient or saw that encounter. I like to capture who coded the record, so the name of the coder. I, then, like to put down a column that states if we’re going to appeal or not appeal, and then our rationale if we’re not going to appeal, and then our rationale if we are going to appeal.

So there’s other elements that you can obviously put in there as well, but those are kind of some of the ones that are going to be important to track. I, then, take that out of my Excel spreadsheet, and I can make some charts and graphs. What are the primary discharge physicians, for example, on all my denials? Which cases had no CDI review on them, yet, they were denied? So, there’s some interesting things you can track and trend from particular data elements in your denials. And why that would be so important for you, certainly because you can learn lessons, you can see trends and patterns, and you can take corrective action. Education is going to be important. There may be a particular practice that has been identified. And one of those I saw identified through this tracking is that tracking the diagnosis of malnutrition in our rationale and the payer rationale, we found in two or– it was three payers that the co-signature, electronically, on the dietary note was not substantiation enough of a diagnosis of malnutrition if that was the only place. And so we incorporated that into a new practice of making sure we clarify with the provider to put that information of that diagnosis of malnutrition in the progress note, not just an electronic co-signature on a dietary note. So that’s kind of an overview. We could talk a lot more about tracking of this information, what we can learn from it, but it gives the audience kind of an overview of what that might look like.

Kelly: Yeah. That was great. Thank you. Are there some specific diagnoses that appear to be problematic for hospitals?

Gloryanne: Yes. As I mentioned above, I think I gave you maybe five different ones. I think sepsis is a big one. And that’s sepsis-2 versus sepsis-3 criteria. Now, having said sepsis, I know our heads spin around about this because there’s a lot of attention in the clinical world around sepsis and mortality, morbidity around sepsis, but the thing is that we need to make sure that in our contracting language with that payer, there may be some language that says the payer has the ability to select the clinical criteria. You need to discuss this with the payer, with your payer contract language around that. And you may be able to, through negotiations, talk about how this can be handled better. In our contracts, they talk about appeals, usually, and talk about how they can deny, and then, there’s an appeal process. You need to make sure you outline that around these specific diagnoses, sepsis being one of them. Acute respiratory failure, acute kidney injury, or AKI or acute renal failure, the encephalopathy, the malnutrition, those are going to be ones that are targeting and are important for you to even clarify in your contracting language that they’re using a particular set of clinical criteria on the basis of rationale of when that diagnosis is valid or not. So, I hope that kind of gives our audience a view of some of those. Pneumonia is another one I didn’t mention in the list, originally, but pneumonia still pops up as a problem diagnosis that is denied quite often.

Kelly: Great. Thank you. And so we know denials can be costly to a hospital organization. What are the three key actionable steps at a high level that hospitals should take to decrease denials?

Gloryanne: Well, certainly, tracking is a big one. You need to have this tracking ability. Now, having said that, tracking means it’s got multiple prongs to it. You need to collect the data. You need to summarize the data, present the data, and those tracking and trending. So, the whole denial tracking piece is a big one because you need to look at your data and see it in a high-level overview and down into the details as well because that’ll tell you where some problems are focusing, just like I mentioned, these diagnoses. Yeah. We can think they’re probably problematic, but our collection of the denial data tells us they really are problematic. And what are some of the issues around them? So that you can, then, say, “You know what?” Like I mentioned with malnutrition, we cannot just accept a co-signature on that dietary note. We have to change our practice. And the physician should be queried to put his or her diagnosis directly in the progress note or the discharge summary, stating that that is the malnutrition diagnosis for that given patient. We put that into a new query form. So that’s an actionable step that can be made using that tracking information.

Next is certainly sharing the information. We keep it within revenue cycle, quite often, but don’t just keep it [laughter] there. You need to share it with your chief medical officer, maybe your medical executive committee, maybe particular physicians in the–your pulmonologist, and let them know about some of these patterns and trends that are going on. We need to make sure contracting– contracting is the next of the three steps. So, there was the tracking and trending and all the different aspects to that. There is provider awareness, communication, education. And there’s that actionable step. And then there is the contracting language that may need to be looked at and reviewed. And you don’t wait, now, to just when it’s time for that contract to expire. You may have to address it now with that payer so that we can make changes and get good results and decrease the denials. So, I hope that was good for three actionable steps. I know the question was three, but [laughter] four things I like to put in there is, we got to have ongoing auditing and be proactive, both for internal audits and external audits, all the time because I think those will also provide good feedback and information to be more proactive rather than reactive to denials.

Kelly: No. That was great. That was great. Thanks so much, Gloryanne. And so do you have any closing comments that you’d like to share with us?

Gloryanne: Sure. Yeah. I think that our topic around denials is something that we all can dive deeper into. It’s not always a very comfortable [laughter] topic, quite honestly, but it’s a reality. And there’s lots of financial implications to some of these denials. As I mentioned, one of the elements to be tracking is the amount that’s being taken back by the payer. This can be substantial. It can be upwards of even $12,000 for an account. And you want to know what the average for your denial is. So, tracking this information is going to be so, so important, having a good process, a team, a denial management kind of process. If you’re using software to track this, who’s the person and individual doing that? Are they entering all the correct data? Are we getting our denial letters to our review team in a timely manner? We don’t want to be going over the time limit, because each of the denials does have a clock ticking on it for us to respond as hospitals, so we want to make sure we’re addressing that. But typically, if you’re getting close to the expiration date, you can contact the payer, and often, they will give you an extension. So that’s something also to be sure you’re on top of with your denial management team. I hope that everyone out there is going to if they haven’t been tracking their denials, trending their denials, and putting together high-level overview of the patterns and trends for these denials, and then saying, “Let’s do some correctable, solutionable actions to decrease the situation of the denials.” So, I hope that was helpful for the audience today.

Kelly: This has been great information. Thanks so much, Gloryanne, really, for joining us today. I mean, this is such a hot topic. So, I think there’s a lot of valuable information in here that people can take away.

Gloryanne: Great. Well, good. I’m glad that the audience will take some things and hopefully work on their situation with their denials. Thank you for having me speak to you today.

Kelly: And Gloryanne, and how best can someone reach out to you if they want to learn more or just talk about denials with you?

Gloryanne: Sure. Yeah. I think they could reach out on LinkedIn, but they can also contact me directly. And let me give the audience that email address. It’s my first name, Gloryanne, all one word, G-L-O-R-Y-A-N-N-E, with the letter B at the end of my name, no space, Gloryanneb@sbcglobal.net. So, if you have a question or want to chat sometime, please reach out.

Kelly: Fabulous. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.

 

If you have a topic that you’d like us to discuss on the Hospital Finance podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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