Fixing Denials on the Supply: Why Outpatient Clinics Must Shift Left

By Monte Sandler, COO, WebPT.

Denials are on the rise throughout the healthcare business, hitting outpatient rehabilitation clinics particularly laborious. Margins are tight, staffing is proscribed, and plenty of clinics don’t have the sources or infrastructure that bigger organizations do. This places them at an actual drawback in the case of managing their income cycle.

Many clinics are merely attempting to remain afloat. They’re scrambling to get payments out the door, then ready to see what suggestions comes from the payers. In consequence, they find yourself with excessive rejection charges, excessive denial charges, and a major quantity of unpaid accounts receivable. It’s a reactive strategy to turning visits into income, and it’s not working.

The Root Downside: Entrance-Finish Errors

At WebPT, we’ve analyzed our income cycle administration information (RCM) throughout our base and located that 67% of all exceptions (rejections, denials, and unpaid accounts receivable) originate from errors made on the entrance finish of the income cycle. This contains improper registration, affected person eligibility points, and a scarcity of prior authorizations.

These are preventable issues. And but they present up repeatedly, as many clinics don’t have the instruments or coaching to catch them early. The reality is, bodily therapists went to highschool for bodily remedy, not enterprise. Many rehab remedy practices are constructed round that medical mindset. In flip, the enterprise aspect finally ends up being reactive and guide.

Answer: Shift Left to Transfer Upstream and Clear up It

The easiest way to deal with denials is to “shift left.” Meaning figuring out root causes and fixing them earlier within the course of, earlier than the declare is submitted. Use information to do that. If you happen to can entry the suitable information, you’ll be able to analyze it to grasp the patterns. Then you’ll be able to deal with the problems which might be inflicting denials, moderately than simply reacting to them.

For instance, practice your entrance desk employees to confirm affected person eligibility earlier than they’re seen. Maybe it’s essential to make sure the affected person is registered accurately, in order that when the invoice is shipped, the payer acknowledges them. Alternatively, chances are you’ll have to test that prior authorizations are in place. A few of that is coaching. A few of it’s course of. A few of it’s utilizing know-how. Nonetheless, all examples require a shift from a reactive to a proactive strategy.

Begin With the Information

All the pieces begins with the info. Rejections and denials normally come from the clearinghouse. That’s structured information that you could manage in a significant method. Unpaid accounts receivable is a bit more subjective, because it comes from the observe administration system and the staff’s follow-up work.

In lots of clinics, individuals are engaged on these claims separately. They’re so deep within the day-to-day that they’ll’t see the patterns. It requires a system that permits employees to flag the explanations for nonpayment, supplying you with information you’ll be able to analyze.

From there, you’ll be able to study whether or not your patterns are related to an individual, a course of, a supplier, or a payer. The numbers inform the story. The information reveals you what to repair, and in what order.

Keep away from the One-Dimension-Suits-All Entice

One mistake clinics could make is over-indexing. Take prior authorization, for instance. Each payer has totally different necessities. If you happen to say, “I’m simply going to get prior authorization for each affected person,” that creates a brand new set of issues.

You want a versatile answer. One that appears on the payer and follows the suitable path for that affected person. In any other case, you’re creating pointless work and frustration.

Make It an Ongoing Apply

Keep in mind, this isn’t a one-and-done effort. You don’t repair it as soon as and stroll away. Payer insurance policies change. Employees turnover occurs. Sufferers change insurance coverage. It’s essential to keep this effort over time. This implies usually revisiting the info, retraining employees, and adjusting processes when essential to account for adjustments. It’s not non-obligatory. It’s a part of the way you run a profitable enterprise in healthcare in the present day.

The Backside Line

Rehab remedy clinics can’t afford to be reactive. Denials are too pricey, and the system is simply too advanced. However by beginning with the info, figuring out root causes, and shifting left, clinics can stabilize their income cycle and focus extra power on delivering care.

The method isn’t simple. Nevertheless it’s value it. As a result of each time you stop a denial, you’re one step nearer to operating a more healthy, extra resilient observe.