Implementing a proactive rejection strategy.

It is commonly understood today that a denial-prevention program is the first line of defense against the expensive rework and lost revenue associated with third-party payment denials. Indeed, most providers have instituted some kind of denial prevention program for scheduled services.

But how many providers have a program in place to prevent denials of unscheduled services? Are you taking steps to ensure that precertifications and prior authorizations are appropriately obtained for, in the very least, those unscheduled services that involve both high risk and high value?

You should consider implementing a proactive rejection strategy (PRS) to prevent denials for such high-risk services. A PRS is a tactical approach that can be cost-effectively implemented early in the revenue cycle. It involves assembling a PRS team to perform daily account reviews, research payer protocols, and make necessary contacts with third-party payers to obtain authorizations and certifications for certain high-risk procedures prior to billing to ensure that payment is not denied for these services. The team should be composed of representatives from patient access, patient financial services, clinical services, and contract-management departments. The PRS program should not replace existing precertification or prior authorization activities; rather, it should be a high-priority element within your existing denial-management program.

Key PRS Components

A PRS program requires several elements to speed implementation and generate rapid results. These include a list of high-risk services, effective training of all staff involved in the denial-management process, clear communication of business rules, and effective means to report results.

High-risk service list. The core group of services on which the PRS program focuses should be those that also are typically the focus of a managed care plan's medical management efforts. Typically, such services are unscheduled services (such as emergency services), but they also may include any services not scheduled through the facility's normal patient-access functions, which run a greater risk of being denied payment due to lack of precertification or authorization. The list of services is best identified through consultation with clinical services and contract-management team members.

Training. PRS team members should provide staff involved in the claims process with adequate training on their new tasks and activities, and address any questions these individuals might have.

Business rules. The PRS team should identify all payer rules specific to each facility's managed care contract and communicate these rules to all staff involved in the claims process.

Reporting package. To facilitate effective PRS management, a reporting package should be developed for monitoring performance. The PRS team should be able to easily generate and routinely review a performance scorecard, daily work lists, and reports on productivity and elements missing from claims.

HIGH-RISK SURGICAL SERVICES

Surgical services that are strong candidates to be included in your high-risk service list include:

* D&C (dilatation and curettage)

* T&A (tonsillectomy and adenoidectomy)

* PE (pressure-equalization) tubes

* Nasal Septoplasty

* Blepharoplasty

* Cataract Removal

* Bunionectomy

* Hammertoe repair

*Carpal tunnel release

* Sclerotherapy

Charles M. Lund is Northeast solution leader, Support Services, Cap Gemini Ernst &, Young, Vienna, Va., and a member of HFMA's Virginia Chapter.

Send your questions or comments to Chuck Lund at chuck.lund@cgey.com.