5 Strategies to Help Interpret Denial Data

Jun 9, 2021

Data and data analysis are an integral part of denial prevention and management. In some cases, denial management teams need help identifying the important information or the trends they should be looking for. The five strategies below can help teams interpret denial data and best utilize it within the denial appeal process.

1. Analyze your trends for information

There can be a lot of information buried inside your denial trends. For example, is there a particular behavior the provider or payer performs that leads to increased denials? Or is a specific payer denying all chest pain claims that do not result in a diagnosis like acute coronary syndrome? In some cases, particularly those with a nonspecific or uncertain diagnosis, looking at past trends will help identify the necessary documentation or protocol for a treatment plan to ensure appropriate reimbursement. Applying analytics to your revenue cycle can assist your team in answering some of these questions.

Another trend worth evaluating is payments that have been received: where you have been paid and where you haven’t been paid. Not receiving payment is often not the same as a denial, but it can indicate a delayed time-to-money. Sometimes, it may also be common for a payer to request supplementary documentation on claims over a certain amount of money. In these cases, the trends in the data, analyzed by provider or by payer, can help you understand where recurring issues in reimbursement exist. By understanding this data, it becomes much easier to solve the problem through training, new or different documentation methods, or better communication with the payer.

2. Review your EOBs and remittance

Explanations of Benefits (EOBs) are handy tools when it comes to examining your denial data. When you evaluate your EOBs, put them in groups to assess specific trends.

For example, group similar procedures together or group similar diagnoses. When it comes to similar diagnoses, one option would be to group patients by initial presentations. Initial presentation of chest pain could ultimately indicate final diagnoses as disparate as peptic ulcers, aortic dissections, acute coronary syndrome, pulmonary embolism, or gastritis.  Hand in hand with this approach, an additional option would be grouping patients by their final diagnoses.

The sequencing of a diagnosis as indicated on the EOB is also a trend worth evaluating. Did the chest pain patient mentioned above lead to the same set of steps in the treatment plan: labs, imaging, EKG, medication administration, CT scan, or even a period of observation, or was there more specific cardiac testing like an echocardiogram, heart catheterization, or stress test? Denials can occur for multiple reasons at multiple stages in the revenue cycle, so it’s important to group similar trends to see the bigger picture.

3. Examine the necessity of the admission documentation

The necessity of admission is often a cause for denials occurring. At this point, it is essential to examine if the documentation is correct.

For example, it may be necessary for some payers to pay attention to details such as if a provider ordered imaging in the appropriate sequence. One instance where we see this might be in a case of osteomyelitis, is an x-ray ordered before a CT scan or an MRI? Some payers will require that providers follow proper protocol and document appropriately to avoid a denial.

4. Evaluate the line items

After evaluating both the trends and the big picture, it is key to look at denials at the line-item level. It is crucial to put your best people at the front lines of denial management and ensure they do their homework in these cases. Their task involves justifying the necessity of the admission, so clinical expertise is essential at this point in the denial management process.

For example, was the entire hip prosthesis covered for a hip or knee replacement, including all relevant hardware? In an orthopedic procedure, were screws bundled with the plate or line itemed as separate entities? The line-item components also come into play with procedures involving blood transfusions. Often, payers do not pay for blood products, but they will pay for the transfusion. Examine the line items and communicate openly with your payer to determine how to document procedures to ensure appropriate reimbursement.

5. Consider individual state requirements

Some states have different requirements, just as some payers do, so it is imperative to do your homework and examine the location of a procedure. A one-day hospital stay will not be paid as an inpatient stay in some states, requiring a “two-midnight” visit. Sometimes, an appeal can be made even if the patient passed away, necessitating the inpatient stay.

With these five tips in mind, gathering data and identifying crucial trends in denials becomes clearer and easier. Incorporating these strategies into your denial management team’s workflow can help them interpret denial data, making the denial appeal process more straightforward and successful.