In 2017, it was estimated that 27% of claims denials in the U.S. were due to patient registration and eligibility issues and that 34% of those denials were avoidable.
Scott Behe, a Senior Epic Consultant with Incisive Consultants, partnered with his client to work to reduce claims denials due to registration and eligibility errors.
This large Pacific Northwest-based health system found that as compared to their peers, their registration-related denial rates were high. They decided to focus on rectifying this issue as part of a large revenue scalability project.
The organization set a goal to earn trophies within Epic's Financial Pulse, a tool that compares peer organizations within their regions.
To tackle the issue, Scott and his client partner took a multi-pronged approach and focused on both education and technological optimization, often combining the two approaches by embedding education within the technology.
“We wanted to support processes with automation as much as possible and when that was not available provide users with meaningful directions for best outcomes,” said Behe.
As with any optimization project, the team encountered several challenges, including outdated and broken build and payor and plan structure that made it difficult for the patient access staff to select the correct plan, and real-time eligibility automation nearly impossible. “Understanding the unique challenges of an organization, including historical decisions, is key to customizing an approach to meet the target goal.”
Scott and his client partner worked to get operational and leadership buy-in and participated in many work group meetings including the Payor/Plan Restructure Group and suggested configuration and optimizations to prioritize to achieve the best outcomes.
“It was essential to build strong relationships with key groups to understand complexities and offer valuable input that would not only meet project goals but also contribute to ongoing successful outcomes,” explained Behe. “Exciting things can happen when operational leadership and IT resources are focused on the same outcome, actively partnering and exploring unique approaches to meet a goal.”
Build items prioritized to help this organization meet their goals included payor and plan restructuring, plan mapping with auto-creation and auto-termination, creation of unique eligibility statuses, and work queue overhauls. Scott's team's efforts resulted in an 8% denial reduction for Medicare, 13% reduction in denials from Medicaid, an overall denial reduction of 20% for all payers, and a 52% reduction in claim edits between 2019 and 2021.
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