Preventing Denials: Root Cause Analysis

Feb 8, 2022

The Importance of Root Cause Analysis

Root cause analysis is an instrumental part of any revenue integrity program as it aims to prevent denials before they ever happen. Getting down to the root cause of the issue is an—almost—surefire way to avoid the initial denial. Knowing your organization’s specific root causes will allow for faster, more effective claims processing from the start leading to decreased time-to-revenue and a strong foundation for denial prevention.

For example, documentation errors at intake are among the most common root causes for denials. These mistakes can happen in pre-authorization due to misspellings or outdated information, but they also extend to medical necessity and provider decisions. For example, a patient admitted with a new diagnosis may need more time in the hospital to learn the proper medication regimen or receive counseling regarding the diagnosis. All of this needs to be documented in detail by the provider and nursing staff to justify the level of care provided.

Root cause analysis is a learning process, though. Instead of a simple claims analysis, the root cause requires an in-depth look at the medical record, among other things, to determine what the internal failure is. It forces the organization to deep-dive into the ‘why’s of denial management, and throughout, you learn more about how the denial process works. Root cause analysis shows an overview of your organization’s specific needs and recurring problems. Continued staff education keeps your current staff up-to-date with current root cause trends and teaches how to implement solutions, which makes for a smoother denial process in the future.

What To Look For

Finding and solving your organization’s root causes is the most efficient denial management solution but requires constant oversight to make recommendations for improvement. Finding a root cause analysis partner alleviates some of that responsibility so that your team can focus their efforts elsewhere. Not all partners are created equally, though. Your ideal partner should have industry-leading technology at their disposal. Detailed reporting is critical as root cause requires specificity to pinpoint the real issue.

Extensive experience is another calling card of an effective partner. Your ideal partner should be transparent about their expertise and how it benefits your organization. Specifically, clinical experience is essential when identifying root cause. Look for a partner with several years of clinical expertise in different designations. Partnerships should be a hands-on experience, from planning stages to implementation to data collection and beyond.

How TREND Can Help

TREND Health Partners’ revenue integrity solutions team identifies root cause trends for your organization’s denials and delivers actionable insights and recommendations. Our cutting-edge, real-time reporting technology was built for clinicians by clinicians to combine all of your claim and denial data into a real-time, single data repository. We bring our years of experience working on provider services, and our staff is kept up-to-date on the latest denial management trends and solutions. We take pride in transparent, trusted partnerships; a strategic, client success forward mindset is at the core of everything we do.