By Kendall Smith, MD | January 30, 2020
I recently completed a comprehensive audit of closed denials for a large healthcare system. One of the major realizations that emerged was that just like Sisyphus and his punishment of having to endlessly roll a boulder up a hill, only to have it roll back down again, this hospital was going to be forever experiencing the same denial for the same surgical procedure from the same payer absent a significant albeit simple intervention with the physicians involved.
Stop and think for a moment. If you’re like most hospitals across the United States, you likely have a regular meeting with various departments around the hospital comprising the “Revenue Cycle.” The goal is to generally enable the hospital staff to work smarter, not harder, by reducing insurer denials and late payments. Now, think about how much progress or impact these meetings have had over the past 12 months. Likely, your efforts have resulted in a slow yet steady contribution to the bottom line but realizing those hoped-for gains that seemed possible after everyone first met have probably eluded you. Why? What if you could show up at the next revenue cycle meeting with an incredibly simple solution that could, in theory, at least double the success rate your group has seen over the past year?
The particular case I was working on was related to an insurer denying onabotulinumtoxinA (Botox) injections as a treatment for esophageal achalasia. A quick review of the clinician’s electronic medical record (EMR) note matched against the insurer’s coverage policy revealed just why the claim never stood a chance from the moment a decision was made to proceed with treatment. The EMR note and the coverage policy bulletin hadn’t changed in the six months since I’d last worked on appeals from the same hospital system for the same procedure by the same physician. The insurer’s coverage was black and white, stating that they considered Botox medically necessary for only the following conditions:
Esophageal achalasia, for individuals who have any of the following:
- Are at high risk of complications of pneumatic dilation or surgical myotomy; or
- Advanced age or limited life expectancy; or
- Have failed conventional therapy; or
- Have failed a prior myotomy or dilation; or
- Have had a previous dilation-induced perforation; or
- Have a sigmoid-shaped esophagus; or
- Have an epiphrenic diverticulum or hiatal hernia, both of which increase the risk of dilation-induced perforation.
I reread, for the third time, the current denial and the clinic note from six months ago. Sure enough, both were identical even though this was an entirely different patient. A quick guesstimate revealed that within the six months since I saw the first denial, the system had likely received 15-20 additional denials on this treatment from the insurer. Yet, the one simple thing that could have ensured payment for the expensive treatment the hospital provided appears never to have taken place. That is providing feedback to the department or physician involved and helping them understand exactly what the insurer would cover for treatment and what the hospital would likely never be paid for.
In this day and age of EMR’s cranking out pre-formatted clinic note after pre-formatted note, no one had thought to meet with the gastroenterology department and review the previous denials and the insurer’s coverage policy. A simple tweak of an EMR template for the procedure would have ensured that the clinicians would have been made aware of the covered indications for the drug at the time of the visit, rather than the hospital finding out the hard way a month or two after the claim was filed. A simple change could be incorporating the coverage guidelines from the payer and then saving the template by the insurer’s name and procedure for recall during subsequent clinic visits. I have seen similar denial patterns involving many common procedures such as intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroidectomy, Botox for migraine headaches, and even nuclear cardiac stress testing in certain patient populations. All of these procedure denials share one common denominator- had the clinician been alerted to the medical necessity language established by the payer at the time of the procedure then the clinician could have incorporated the appropriate language within the procedure note to establish the medical necessity of the procedure in payer-specific language or considered an alternative procedure if available. The challenge lies in how to find these patterns and then once found how to act on the information.
Think about running a list of all of your denials by payer for a 6 to 12 months period and matching them against a similar list from present day. If you see certain procedures or DRG’s coming up regularly on both lists, then you’ve got your targets identified. Review the clinic or hospital notes against the payer’s coverage policies, print them out, and then arrange a quick meeting with the department chair to review your findings and the cost of the denials over the past year. Then suggest a simple, non-intrusive way to stop future denials. Have someone in the department revise the procedure note to a payer-specific note, which includes the payer’s coverage policies. Then, the clinician is aware of the policies before the procedure, and can simply check a box indicating how their patient’s condition fits within the coverage policies. Re-visit your denial list six months down the road. The odds are you won’t see that procedure anywhere on it, and you’ll start to see some eye-popping improvements in your denial rates.