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 lots of clinics don’t have the sources or infrastructure that bigger organizations do. This places them at an actual drawback on the subject 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. Consequently, 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 Drawback: 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 consists of improper registration, affected person eligibility points, and an absence 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 facet finally ends up being reactive and guide.

Resolution: Shift Left to Transfer Upstream and Remedy It

One of the best ways to sort out denials is to “shift left.” Which means figuring out root causes and fixing them earlier within the course of, earlier than the declare is submitted. Use information to do that. Should you can entry the appropriate information, you possibly can analyze it to grasp the patterns. Then you possibly can deal with the problems which can be inflicting denials, relatively than simply reacting to them.

For instance, prepare your entrance desk workers to confirm affected person eligibility earlier than they’re seen. Maybe it’s good 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 must examine 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. Nevertheless, all examples require a shift from a reactive to a proactive strategy.

Begin With the Information

All the things begins with the information. Rejections and denials normally come from the clearinghouse. That’s structured information which you could set up 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, persons are engaged on these claims one by one. They’re so deep within the day-to-day that they’ll’t see the patterns. It requires a system that enables workers to flag the explanations for nonpayment, supplying you with information you possibly can analyze.

From there, you possibly can look at 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. Should you 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 resolution. One that appears on the payer and follows the appropriate path for that affected person. In any other case, you’re creating pointless work and frustration.

Make It an Ongoing Follow

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. Workers turnover occurs. Sufferers change insurance coverage. You must keep this effort over time. This implies often revisiting the information, retraining workers, and adjusting processes when essential to account for modifications. It’s not elective. 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 just too complicated. However by beginning with the information, figuring out root causes, and shifting left, clinics can stabilize their income cycle and focus extra vitality on delivering care.

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