ASCs continue to face challenges concerning denials and appeals, but there are ways for surgery centers to improve their performance in both areas. Here are 10 tips for strengthening ASC processes that can reduce the likelihood of denials and increase appeals success from a recent webinar, "Denials and Appeals: Expert Insight and Tools to Boost Collections."
1. Be vigilant.
As soon as you receive a denial, begin working on it to determine the cause(s) of the denial and what's likely needed for the appeal. Staying on top of denials and acting fast are essential to successful appeals and reducing the likelihood of denial occurring again.
2. Establish processes — and follow them to a T.
Good policies and procedures can help decrease denials and expedite appeals. Making sure staff consistently follow those policies and procedures can also help in these areas.
Such consistency serves another purpose: When you experience a denial, you can more effectively review your policies and procedures to determine whether a change is needed to decrease denials. If staff frequently deviate from policies and procedures, such an audit and process improvement initiative will prove difficult.
3. Educate and train staff.
Staff education and training concerning denials and appeals should be ongoing. Staff should know exactly what to do when your ASC receives a denial, the importance of acting on it quickly, and the process they should follow to best ensure the development of a complete appeal. Whenever processes, policies, and procedures undergo changes, staff should receive appropriate education and training on those changes so new approaches are followed properly and consistently.
4. Audit performance.
How well is your ASC performing concerning denials and appeals? To answer that question, conduct an audit. Examine everything from your denial rate, to the speed a denial is acted upon, to your appeals success rate. As you work to implement changes, make sure to benchmark results and acknowledge success.
5. Benchmark results.
To help ensure any adjustments you make to processes that can affect denials and appeals have their intended results, benchmark changes in performance and results against internal metrics. To determine whether your ASC is generally performing well or poorly in these areas, pursue external benchmarking opportunities so you can compare your center to like ASCs.
6. Acknowledge success.
When your team successfully appeals a challenging denial, finds a way to strengthen your processes, or makes any other positive impact to efforts to reduce denials and improve appeals, acknowledge this success. Inform staff of the difference they've made verbally or in writing. You can go even further by rewarding success. Small gestures like a gift card for coffee, a free lunch for an individual staff member or the team, or even a little extra time off can help further motivate staff to continue focusing on these key areas.
7. Push back when treated unfairly.
Denials are unavoidable — even if you do everything right. Why? Payers sometimes accidentally (we hope) deny clean claims. When that happens, they should be willing to make things right by accepting and processing your appeals. But if improper denials become more commonplace or it seems like a payer is making you jump through hoops to submit appeals, don't hesitate to reach out to the payer and challenge these tactics. Payers should treat ASCs with which they have contracts like partners, not adversaries.
8. Negotiate your rights.
When negotiating a managed care contract, work to ensure there's adequate time for you to review denials and submit appeals. Payers will often push for a shortened window that can make it more difficult for an ASC to gather the documentation and evidence it needs to submit effective appeals. In addition, make sure the contract includes language about the payer's responsibilities, including processing and responding to appeals in a reasonable timeframe.
9. Account for increased delays.
The COVID-19 pandemic has slowed many payers' correspondence, adding to the time it takes for processing claims, sending denials, and reviewing appeals. Take the potential for delays and any slowing down that you observe and measure into consideration when determining how quickly you should be working to submit claims and appeals, resolving accounts receivable, benchmarking performance, and making ownership distributions.
10. Know when to fight — and when to move on.
While all denials are worth appealing, not all denials are likely worth continued appeals because of the time and associated costs required to complete appeals. A good best practice to consider is removing low-dollar denials from the list of denials to work if their initial appeal is denied.
While it may be difficult to walk away from any denials because you are giving up on collecting what you rightfully believe you owe, consider the 80/20 rule. Also referred to as the "Pareto Principle," it states that 80% of a company's business comes from 20% of its customers. While this rule may not exactly apply to your surgery center, it helps explain why most of your efforts concerning denials and appeals should be focused on high dollar claims rather than those not as likely to make a substantial impact on your bottom line.
To learn more about ASC denials and appeals, watch this on-demand webinar!