Why Revenue Gets Stuck: Finding the Operational Breakdowns That Delay Payment

Cameron Cordigiano: Hello, everyone. This is Cameron Cordigiano with Becker’s Healthcare. Thank you for joining us for today’s webinar, Why Revenue Gets Stuck: Finding the Operational Breakdowns That Delayed Payment.

Before we begin, I just have a few quick housekeeping instructions. We will begin today’s webinar with the presentation, and we’ll have time at the end of the hour for a question and answer session. You can submit any questions you have throughout the webinar by typing them into the Q&A box you see on your screen. Today’s session is being recorded and will be available after the event — you can use the same link you used to log into today’s webinar to access the recording. Finally, if at any time you have issues with the audio or visuals, please try refreshing your browser. You can also submit any technical questions into that Q&A box, as we are here to help with that.

I’m pleased to introduce today’s speakers. First, we have Chris Martin, Senior Vice President of RCM Services at Coronis Health, and also Dan Douglas, Vice President of Revenue Cycle at Coronis Health. Thank you, Chris and Dan, for being here today, and I’ll turn the floor over to you both to get us started.

Dan Douglas: Thank you, Cameron. I’m Dan Douglas — I’ve been in revenue cycle for 30-plus years. I started really on the back end. I’m from the Boston area, but I’ve lost the vast majority of my Boston accent — if you catch me later, it might appear in some capacity.

I really started, like I said, on the back end, and I had very little familiarity with the front end of the revenue cycle — and that, as we all know, is what creates the problems. If you’re not creating process on the front end, you’re going to have a problem on the back end. There’s no question there are fundamental items here that need to be taken care of. Unquestionably, I needed to get that perspective, so I took a position working directly at a hospital, gained significant knowledge, and really learned what I needed to learn to be effective on the back end. Sometimes it’s too late — sometimes it’s fatal. As we all know, there are certain aspects here that need that level of adoption on the front end. So we’re going to talk about a variety of things today. Chris, do you want to do your intro as well?

Chris Martin: Sure. Thank you, Dan. Welcome, everybody — good afternoon. My name is Chris Martin. I’m Senior Vice President of Coronis Health’s RCM Services. I’ve been with the company about four years, and I’ve been in revenue cycle close to 20.

I’m currently located in Dallas, Texas — you’ll probably only hear an accent because I’ve been here about 10 years; I’m originally from Dan’s area, in northern Connecticut. I’m going to be talking to you about some of the major pain points I’ve seen throughout my career. I started, like Dan, in positions like PFS director and Vice President of Revenue Cycle for hospital groups — things I’ve seen over the years, and ways I’m working with some of my partners now that we’ve come up with strategies to help. With that, I’ll switch it back to Dan.

Dan Douglas: Thanks, Chris. So, like I said, everything we’re going to talk about — there’s going to be a lot of information. I can promise you it will be painless. I can’t promise it’ll be quick, but as Cameron mentioned, there will be questions at the end that we can certainly follow up on.

Similar to Chris, I’ve spent a great deal of time working with a tremendous number of hospitals — working as a vendor, working directly on-site. Currently, like Chris, we go to so many different hospitals, we see so many different flavors. We are system-agnostic here. There are so many barriers, as we all know, that require process on the front end to get where we need to be. So I’ve talked about process, documented process, training, and team adoption — and everybody knows how challenging that can be, because people don’t like change, and occasionally we have long-term colleagues who are resistant to it. So it requires that daily hygiene as well.

Dan Douglas: All the topics we have for these five pain points have this in common: they need daily hygiene and monitoring. And the last piece that really needs to be there is support from the C-suite — without the teeth, without the consequences for what happens next when process isn’t followed.

I’m referring to ordering physicians — all aspects of what drives a revenue cycle and creates challenges downstream. If it’s not painted correctly originally, it’s going to look really awful downstream. So the five core areas here are provider enrollment, eligibility, authorization, that medical necessity documentation process, coding and claim edits — all of it. You all know these elements; you deal with them daily. These are the challenging aspects, and again, it’s process-driven. Automation can be a part of this as well, but ultimately a lot of this requires patient engagement, and with that patient engagement, it requires manual processes occasionally.

It’s a moving target — there’s really less room for anything disconnected. Everything is connected: the knee bone is connected to the hip bone. It really gets down to having those guardrails at scheduling. Things cannot be scheduled without an ICD-10 code; things cannot be scheduled without the CPT codes that go with that scheduled event. If there’s no diagnosis, no CPT code, there’s no way to run eligibility properly at scheduling, and no way to build the additional cadences needed to make sure you have a good fiscal event downstream. And ultimately, the claim logic relating to coding — we’ll talk about that too, and how it needs to be process-driven as well.

Looking at the breakdown — enrollment, eligibility, authorization, medical necessity, coding edits — it’s very easy to point fingers. We know this because there’s a daisy chain here: one breakdown, and we have a challenging fiscal outcome. So there needs to be that level of connection and synergy. I’m talking about all aspects — case management and physical areas need that synergy too. I’ve seen occasions, historically, where claims go out without utilization review, or with a utilization review that’s pending — that’s an appeal status, and the claim still goes out; it’s an auto-denial, and try unraveling that. Those are things that need process.

Following that revenue to get it out the door — everybody wants to get the bill out the door; nobody wants DNFB, nobody wants DNFC, nobody wants those KPIs beyond the traditional standard. However, there needs to be a level of quality as well, especially with high dollars. So it could break long before the claim does — that’s the challenge here. And as we know, a lot of that breakage can be fatal. Authorization can absolutely be fatal — that applies to a VA claim, that applies to not getting authorization for surgical services. We know things can change clinically within a surgery — in a scheduled or elective inpatient case, things can change clinically — but you need to have those guardrails, that process, that documented process for: when things change clinically, what do we do fiscally?

Chris Martin: So I’m going to pick it up here — thank you, Dan, that was a great intro. I’m going to talk a little about what happens before the service is even scheduled, and things we’ll see down the denial chain: provider enrollment.

One thing I want to be very clear on: if I’m looking at my follow-up queues and asking, where’s my AR sitting, why is this still aging — I’ve addressed everything, I have this big hold for credentialing, I keep sending it to somebody, they look at it, maybe not — well, what a lot of people don’t realize is it may not be credentialing at all. It could be the provider-enrollment component. The two are not the same. Now, they run hand in hand — credentialing is a prerequisite for provider enrollment — but the major difference is that credentialing verifies the provider is qualified to practice: their educational history, certifications, licenses. Provider enrollment looks at the financial and the linkage — basically, taking your group and linking it to your payer networks, to your managed care networks, making sure that step is taken.

So you have a group, and this could be within your revenue cycle — it doesn’t need to be part of credentialing. I have teams here at Coronis Health of 100-plus FTEs who do nothing but provider enrollment, because this is actually taking that linkage and making sure the step is completed. If you do that and coordinate it, your credentialing bucket for your holds — your AR holds — starts to shrink.

So where does it break? We could have data not ready — that’s really important. One of the main things is to centralize your provider data, and on top of that, standardize your intake. Because your data may not be ready, provider information may be incomplete, some payers are slower than others, or you could have a mistake in the dates — you think a person is enrolled, but you actually only enrolled them through a certain month. So there are different pieces. What does that do? Revenue sits there, it ages, your days go up, but it’s nothing your teams within PFS can acknowledge or fix without sending it upstream — unless they have that collaboration and work in parallel with the credentialing team.

One more thing on provider enrollment: not only is it very critical that it gets set up correctly, but this can be two different groups, or it could be within one group. I’ve seen it work differently, and the trend I’ve seen in the last two years is a big call for the provider-enrollment service specifically, because people are realizing the difference between credentialing and provider enrollment — what’s truly a revenue cycle issue as opposed to a clinical and quality issue sitting in the credentialing department. I’ve engaged in different opportunities where we’ve seen our clients’ days go down within 30 days of installing these dedicated groups — the demand is there. It’s a real issue.

Chris Martin: And on that, we’re going to move right into scheduling — patients are here, what do we do now? We’re going to move into eligibility. Danny, would you like to discuss the eligibility section?

Dan Douglas: I’d love to, Chris. So everybody knows what the problems are here: it’s Medicaid, it’s Medicaid carve-out, it’s Medicare, it’s Medicare carve-out. It’s confusion to the patient — what do I have, where am I going, do I have an ED-only plan, do I have a plan that’s going to cover the service?

And again, there need to be guardrails — a guardrail at the point of scheduling. We need to run eligibility at that point, whether it’s manual or a batch overnight environment; that can certainly work as well, as long as there’s fine-tuning relating to it. Of course, a lot of you utilize a batch environment for eligibility, but that cadence needs to have some hierarchy to it as well. If it’s an elective inpatient event, it should be run chronically, in some capacity, most especially if it’s Medicaid or a Medicaid carve-out — those plans can go in and out of coverage every day. Looking at an elective event, there’s tremendous risk relating to eligibility with those kinds of plans, and naturally a variety of providers won’t accept traditional Medicaid for a number of elective or cosmetic events as a result. So generally there needs to be a cadence — eligibility at the point of scheduling, eligibility at the point of pre-registration, and a pre-registration call built into this as well.

There needs to be an environment where an elective inpatient case is treated differently than a lab test — there’s no question about that. But this is something that needs that everyday hygiene I keep referencing, relating to process — documented process. What do we do? Is there an inactive payer, who are we calling? We’re calling the ordering physician again, but if the ordering physician is not providing — or is trending toward not providing — active insurance information, that’s a conversation the C-suite needs to have with that particular ordering group. There’s no question there needs to be some teeth involved here. Otherwise we’re looking at rework, phone calls that require additional effort, and we’re taking these registration clerks away from patients, which isn’t what we want either.

So leakage is something that, if we don’t do our due diligence on the front end — once that point of scheduling happens, if it’s documented and measured and adopted by staff, and staff performance on eligibility can be measured, documented, and, frankly, publicly shamed — I have no problem with publicly shaming — this is something that needs that level of diligence. The patients deserve it; they deserve a good environment here. This is a big part of patient survey scores: did I have a smooth day of scheduling, was the date of service a good date of service, did they ask me to wait 45 minutes to double-check my eligibility, did they have to call my out-of-state Blue Cross and stay on hold for two hours? Then we all know what happens — clinical staff is calling you, asking what’s going on, the patient isn’t happy, there’s potential rescheduling. This is why there need to be those parameters at the very beginning of scheduling.

Chris Martin: All right — well, that brings me right into authorization. It’s the next step, right? What I’m going to focus on here is outpatient specialty services and authorizations — radiology, cardiology, that type of thing — and the effect they can have downstream, for pickups that can otherwise be done very easily.

Dan Douglas: Correct — documentation. Is it done well the first time? Are they picking the right documentation, the right dates? These are things that come into play.

Chris Martin: So you have your documentation gaps, and I see this a lot, especially in the radiology world — we’re waiting on documentation, waiting on documentation that needs to be cleaned up, and sometimes safeguards need to be put in place to make sure that happens. Otherwise you’re starting a wheel with broken spokes; it’s never going to work.

And all you’re going to do — this is where authorizations are part two — is, if you don’t get your documentation right and cleared, you’re going to have a denial. What happens is the leakage isn’t just the roughly 26% that ends up getting written off, but also the effort that your back office is putting into unnecessary appeals for these denials. So when you see spikes in denials of this kind — generally basic coding or edits coming through around authorization — you can slim down that back-office staff and increase your cost-to-collect efficiency by putting the emphasis on structure and process up front.

And if those get put into play, your denials go down, your days go down, your over-90 AR goes down — because a lot of times these denials compound, right? If you’re doing a lot of mass appeals for these authorizations, you have to go back and look: OK, where is my process breaking here? Is it a specific payer? You can take your denial information and build steps within your system, based on payer rules, to prevent it. If you keep a standard cadence of monitoring your denials and feeding that information back up front so it gets fixed there — rather than running downhill, where we know back-office costs are heavy to get someone to the level of an appeal specialist, and if we’re talking inpatient, it’s even more expensive — you’re taking your trending and turning it into a process you can use in your revenue cycle, then pushing it up a step further to make structural changes within your system, leveraging technology.

This is a place where you’d leverage technology to get that first pass — and that’s really what we’re looking for: first pass, not getting held up in your scrubber or ending in a denial. Which authorization piece creates the most pain? Well, they all do, but number one is missing clinical documentation. If it’s not captured correctly — whether it’s the EMR, whether it’s specific providers — it just sets up a chain of events that’s going to end in revenue leakage, both in cost of staff and loss of revenue. It’s a double-edged sword.

So you could have an expired authorization — maintaining that your people are checking for a CPT mismatch. A lot of times I’ve had authorizations go through and nobody had noticed they requested the wrong CPT code. And then, exposed medical necessity is at the end of pretty much all of it — that’s the key that holds it together. But there is a way for the back office to take its authorization information and develop it into a correct process, based on the appeal work they have to do anyway, and then push that upstream so it’s done first by that unit, or even better, by your system.

Final thing on prior authorization: it’s becoming more digital. However, it’s not an end-all solution — it doesn’t automatically make it simpler. You still have exceptions; data out is only as good as data in. If you look at where we are now versus a year from now, you’ll see prior-authorization API requirements coming due January 1st. Meeting those timelines is going to be critical, and figuring out how much of the prior-authorization process can turn to technology to take care of a lot of the human error we see today is going to matter.

Chris Martin: All right, and now medical necessity — this is the meat of it. Dan, I’ll let you discuss.

Dan Douglas: Thanks, Chris. So there are two criteria with medical necessity. There’s the regulatory aspect, where we have the ABN component and the notice of non-coverage with a commercial plan — the ABN specifically with a Medicare plan. And then we have the fiscal-risk component, of course, where we have to ensure that what’s been ordered is what’s proposed and what’s documented.

Being able to provide diagnostic codes, being able to provide documentation of conservative measures performed, into whatever platform you’re using — that can give you an idea of whether this is going to pass or not, based on payer policy. Those are the criteria, and those are absolutely things that I’ve used in the past that really work. It’s what happens when it doesn’t pass, or it’s yellow — we have a problem here, what do we do? That’s where we have to go back to the actual ordering physician: do we need a different diagnostic code? Do we need more validation of conservative measures?

And what we hate to get to is any level of peer-to-peer review — nobody likes that, physicians don’t love getting a call about it. Can we provide additional documentation? It’s not necessarily paperwork; there may be a genuine medical-necessity challenge, since Medicare has new authorization criteria that apply to things masquerading as cosmetic — I’m talking about blepharoplasties, septoplasties, ablations that could be considered as potentially masquerading as something without medical necessity. Medicare creating, requiring, and supporting an authorization requirement ties directly into this.

If we have the documentation complete, if we have validation of all these aspects, if we have buy-in from the ordering doctors to provide details about what they’re going to do, we don’t have to create additional problems downstream — we don’t want that patient to be rescheduled. That’s a dissatisfier, and as we all know, patient survey scores are, for lack of a better word, a really big deal. So it’s definitely something we need to ensure on the front end, so we don’t have downstream denials relating to medical necessity that are nearly impossible to unravel at that point.

Sometimes the clinician was thinking it was appropriate, but the documentation doesn’t describe that — and that can result in a need for trending, for a CDI program, and for education for ordering physicians and physicians generally regarding their documentation. It has to align to payer policy, it has to align to diagnosis, it has to align to the CPT code, as to what’s physically being scheduled matching what was ordered and what preceded it. We all know things change clinically, and there needs to be a process relating to that — but the vast majority of these items can be mitigated on the front end if that process is driven properly.

The ABN is the other aspect, as I mentioned, with Medicare — Medicare contending they’re not going to pay for it based on the criteria. The patient has to make that decision dynamically: do they want the service, knowing Medicare isn’t going to pay for it, are they going to pay for it themselves, are you going to convert it to self-pay on the back end? That’s something that needs to be documented — it’s very regulatory. Joint Commission can absolutely request a pull: where are your ABNs? And if you don’t have them, they’re going to require you to have a process for it — it could be more punitive. It’s a small set of criteria, and where you land depends on the scale of your provider and your hospital and where this patient is going, but it’s something that has to happen. So those are the two criteria of medical necessity.

And it applies before care, during care, before the denial, and after the denial — and it needs that synergy I talked about earlier with case management, which applies to admissions as well. There needs to be synergy to validate where we are with this admission, criteria, process, and the ability to ensure a bill doesn’t go out that hasn’t been through appeal or utilization review. These are all leading indicators of denials — and of peer-to-peer, as I mentioned; that’s something we see trending with a particular physician, and a lot of facilities will try to identify who their top five physicians generating peer-to-peer reviews are.

It could be high-tech radiology — they’re not giving the criteria to get an easy pass, and a lot of these payers will give an easy pass if you have your ducks in a row on criteria: they’ll pass medical necessity, the authorization will flow, it’ll get approved. But if not, you’re looking at rework, patient angst, and physician angst as well, if there isn’t that level of education.

Chris Martin: All right, so I’m going to touch on the last friction point we have here — the timing of it is good, because it’s the last touch the middle of the revenue cycle gives us before we go into the billing process. And that’s claim edits, coding edits.

So how do we determine if we have a coding-edit problem? Well, the first place to look is your denials — denials by reason and by payer; that will tell you very quickly. Then you want to standardize and say, OK, what are we missing? What kind of edits am I looking at — do they have a particular theme, am I seeing trending, is it bundling, is it modifiers, CCI edits, LCDs, is it payer-specific? If you find it’s payer-specific, even better — because you can build teams and processes in your business office to handle those specific types of denials and appeals. You may have a setup where a work item goes back to a coding team under a different department to work, then goes back to your billing and follow-up teams.

What happens a lot of times is it goes outside of there — you run into, are these truly coding denials? I know a lot of people have heard HIM directors yelling, “you’re sending me non-coding denials.” So really getting those processes in place first is essential, and then you can build off your trends. We have a couple of suggestions: you want to update your systems at least quarterly for regulatory and systemic things, but when you have payer-specific issues you’ve identified, that’s where the managed plans come in — the managed Medicares, the managed Medicaids, they all have payer-specific requirements. You want to identify those on the front end, move that logic up front, and get it into your system so they’re caught there — because many times, once those are caught, your follow-up staff suddenly have a lot less work to do.

So you’re getting a double win: you’re getting revenue at a timely pace, and you’re reducing your overhead in terms of internal cost. That’s a double win, and it goes right to your bottom line.

Another thing — we call this the “false victory.” A lot of times I’ve come into the back end of facilities and there’s confusion about what’s “accepted” versus “paid” — they’re not the same thing. You get these 277 responses, it’s been accepted, and then it’s kind of buried, right? We’re looking at resolution — acceptance really does you no good except as a verification; it’s not a resolution. It can still fall down and create problems for you. So first-pass acceptance is not a sign that everything is good.

An important part of this too is the claim logic I’ve been talking about within your system — setting up your rules, regulations, checkpoints. It cannot move slower than payer logic; you want to stay up with the payers. The last thing you want is to get caught behind. You may have a payer with a 90-day filing limit, and all of a sudden new regulations come up and you’re 90 to 120 days behind the game, with a ton of claims they now consider timed out — now you have to do a mass appeal, and so on. So it’s very important that we’re taking information from the back end and moving it up front, so the front end has the same information — they can make whatever corrections they need to, based on plan and service, and we eliminate that lag.

Dan Douglas: So we talked about five different things — these are all items, and I know I have to put out a scenario I think anyone who’s been in the patient accounting world can relate to.

You’re in a situation where you’ve got your staff — your billers, your follow-up staff, your denial management team, your cash posting teams — trained, up on the systems, they’re good, they’re hitting production, their quality is excellent. We have tons of new business coming in — this is fresh business. Yet my days are still high, my net collection rate isn’t improving. Why? I challenge you to look at one of these five things, because more good business, if it’s falling under a broken process, is just going to saturate and become a bigger problem for you.

So if you can hit them one at a time — say, “hey, I’ve signed off there, we’ve got a good process” — all the truth is in the data. Truth is always in the data, and we have the data on the back end to see what the final product was. Now, how could we use that information to better educate our system upstream? And that’s really the key to the presentation: it’s operating-model change. We want to change from being a reactive model — everything’s going through, I did everything right, I reworked it, I wrote the appeal, 60% success rate on appeals, still wrote off 40% — that’s a reactive model we want to prevent. We want a preventive model: what’s my root cause, how do I tie the data to the root cause, and who do I communicate it through to get it moving?

That’s really the key — stop, target, and then feed it back. And the better partners you have within the revenue cycle who take that on, because it makes their job easier, their job better, their metrics look better — they love you for it, “oh, you made me look great.” That’s what we want to get to. It’s really the loop: do we want to be the end stop, or the beginning of process change? That’s what’s critical.

So, three things to do: pick one of these five, trace it backward, and close the loop. Look at your denial information, look at your hold information, go back and see, pick one of these and trace it back up through.

Cameron Cordigiano: All right, so I’m going to leave some time for Q&A. Cameron, thanks so much for that wonderful discussion and presentation. We will start the Q&A session now — if you have any questions, just pop them into that Q&A chat, and we’ll get started with the first question.

Dan Douglas: I can take this — good question. I like to talk to a lot of my colleagues supporting local hospitals, maybe through HFMA or something, because we’ve got to beat these payers.

They’re utilizing things that make our lives more of a challenge every day, whether they’re using AI or other tools. In terms of whether it’s something internal, even those breakdowns — as Chris and I talked about — it definitely requires you to dig deep; there’s no other way. You’ve got to dig into the denial — it’s a story, it’s a puzzle, something that needs to be figured out. There’s no other way to distinguish it, really, than reviewing whether it’s an internal breakdown or something you know pretty quickly is, say, a Blue Cross local community plan. And I think talking to other providers is a good way as well.

Chris Martin: Yeah, and another way to look at it is the way I’ve done it in the past: if I think I’ve fixed a denial issue and they’re still popping up, I’ll trend it by payer.

If I see the same one, two, three payers, I know it’s a payer issue, because the other payers are processing the claims just as we put them out. So really, if you look at your initial pull and you have payers all over the map, it’s generally a process issue — you have to address that. If it’s one, two, three payers, it’s definitely a payer issue, Chris.

Chris Martin: That’s really the challenge, right? Because, like I said, technology could solve a lot of manual processes — however, it has to be monitored. It’s not going to think outside the box the way a human does; it’s going to be rules-based.

So it has to be monitored. If you throw in something automated for, say, authorization, it will spit out lots of funny stuff, especially anything involving clinical review — it can help, but it’s not the final solution. You always need those safeguards in place. You’re going to have exceptions, and you can tell a lot from your exception rate. Hospitals I’ve worked with, as they bring in technology, will say, “hey, we’re trying to automate 50% of this pool of business, prepare to help us with this, this, and this.” And what I usually see is: against their guess of 50%, it’s usually closer to 10% from what I’ve seen so far. So it’s still all that human element that has to be there — sometimes we even have to add people to catch the exceptions and try to fix them. My answer would be it has to be a mix: technology and AI built in can save you some of that work, but for human review and human thinking, we need to keep those strengths where they are to be successful.

Dan Douglas: Yeah — so even with all this great technology, there still need to be some guardrails put in place so it doesn’t come right off the tracks. There’s risk, unquestionably.

A lot of providers we deal with do not want to be the beta site with 100% AI in an environment. As Chris mentioned, the exceptions need to be reviewed, and the scale of the exceptions matters — is every other one of them not binary enough, not clear enough, or do we have additional issues on our end that are creating that exception? There needs to be diligence there, and starting out at a lower level — something day-surgical rather than something a lot more clinically complicated — is really where that confidence needs to be built.

Dan Douglas: There needs to be support from all directions to get there — at any point that’d be a wonderful thing, right? It really would. What it’s going to take is the big health networks really banding together and pulling their highly established provider leaders to make a stand.

I think it can happen — the people are in place, it’s just coming to a general consensus and working together that will make that happen. But that would be in conjunction with any regulatory environments that can be promoted, in terms of patient satisfaction and “no surprises” — those things are definitely developing, and an avenue there. If that can apply to authorization and medical necessity, and getting payers to not just deny things unnecessarily to hit a certain volume of denials as a KPI, we need to push back — band together to push back, as Chris did.

Chris Martin: Yeah — and things like risk-adjusted contracts, that put payers at some financial risk when they don’t come through on their obligations, really have to happen and be standardized rather than a series of one-offs based on who has the best relationships.

It has to be standardized across the country: this is wrong, and if you continue this behavior, here’s a penalty for it. I’d start with contracting — that’s where our thought-leadership as an industry could really take the pull, take the stand, and get some leverage. That’s ideally where we need to get to.

Cameron Cordigiano: Yeah, it seems like it would be great if all the providers could come together and kind of force that from the payers, but it seems like there’s still a little bit of work to do on that front.

Chris Martin: Yeah, that’s the trick.

Chris Martin: Yeah — I’ve seen that, and basically what’s happened is it was probably an error made by either the credentialing team, or a lack of understanding of that piece of it.

So the provider-enrollment team — that’s where a lot of our work and our groups come in — we go and correct that with the payer and make sure the correct paperwork is submitted and everything gets covered. We do two things: not only provider enrollment, but going back and correcting provider enrollments that were done incorrectly. It could be something as simple as a name change — a married name, a divorced name, a hyphenated name — those have to be as specific as possible, and if it doesn’t match, it’s not going to work. It’s an everyday event. And if you don’t have a team that looks at that or understands it, then it’s going to sit in a credentialing hold until it falls off to a timely write-off — that’s why it’s important that we’re looking at this: is it truly a credentialing issue, or is it “I did all this paperwork, they’re only looking at this side of it”?

Chris Martin: I would segment by payer requirements, because if you take the most stringent rule and apply it broadly, it’s going to catch it — but then certain things might not get billed to a certain payer because of that more stringent rule.

So it’s kind of twofold: you don’t want to get too customized, because it’s all connected. Payers certainly have certain criteria and rules, but if you have all that criteria built in, these questions can be applied to a claim edit, or applied to a claim check for that matter, so it doesn’t even get to an edit — it’s caught before it’s still in the system and hasn’t hit the clearinghouse yet. These aspects around payer specificity can be customized, but you just don’t want to get too customized — it has to be controllable.

Dan Douglas: So really it’s kind of case by case, and at that point it’s about what makes the most sense for that specific situation or submission. It also depends on your system — you could take the most stringent payer rules, load those up, and then also account for which payer was selected at the time.

So it depends on the system, and how much structure you can build in with safeguards to make sure you don’t lose anything — but it has to be tested pretty thoroughly. And no question, payer criteria changes by the wind, it seems, so it’s something that needs the potential to be maintained; it’s almost a full-time job to maintain that level of rule criteria. So having some level of a check built into the system is ideal, but it can only go so far for a certain customization or volume level before it slows everything down — every account is trying to get out the door, so it has to have that risk hierarchy as well. If you see a denial relating to something that could require a claim check before it gets to the clearinghouse, that gives you multiple levels of guardrails, which is ideally what you want — especially with multi-specialty scenarios where you might be doing behavioral health, dermatology, dental, or other services people are bringing in now, each with very specific rules. So you could do it by service, by payer, or both — it depends on the capacity of your system.

Dan Douglas: Yeah, I think before it hits the downstream area — really, if you’re continuing to see challenges connecting the dots on medical necessity, eligibility, and authorization, you’re going to know if you have breakdowns, if things get scheduled without the particular criteria required to make sure we don’t have downstream denials.

I’m referencing diagnostic codes, CPT codes, payer eligibility, and the various cadences of payer eligibility. If you don’t have these guardrails in place, that’s as predictable as rain — looking at it downstream, in a lot of cases it’s simply too late. And as Chris mentioned, you want to shift that denial detection to the front-end environment; you don’t want to look at it after the fact — you’ve largely lost, and you’re spending time for the most part. So if you already know you have breakdowns in these connections — you’re not getting what you need in orders, you’re not getting what you need in authorization processes — you’re going to have denials. It’s inevitable.

Chris Martin: And one way to do it too is to look at the steps we listed: if the one before you is broken or not working — say authorization is having trouble getting authorized before billing — that probably means something upstream is missing. So that would be a signal for…

Cameron Cordigiano: Great — thanks for sharing a couple of those examples. I think we hit on all of the questions from the audience, so we have a couple of minutes left. Any closing thoughts, Dan?

Dan Douglas: Sure, I’ll go. Well, first of all, thank you, everyone — I know it’s Friday afternoon and everyone’s very busy, so thank you for taking the time to listen to us.

We both love to speak on these topics — we’ve been living them forever, and sharing what we’ve learned with other people is very encouraging. So really, my final takeaway is: look at your metrics, look at your holds, find trends, take those trends and find root cause. Then you can build process. The next step after that is you can automate the process — that’s when you’ll really start to see things go in the right direction. But thank you, everyone — I do appreciate your time.

Chris Martin: Thank you as well — really appreciate Becker’s inviting us to this event. As you can tell, we’re both very passionate about revenue cycle — something that, as a kid, I never thought about; I didn’t know what revenue cycle was.

It’s definitely something I’ve been in for a long time, and I can’t imagine doing anything else at this point, honestly. So happy Friday — we’ve all had a long week. I’ve been traveling for the majority of it and putting this together on top of a variety of other meetings. We all have. So again, thank you for taking the time to connect with us — hopefully it was a little bit painless.

Cameron Cordigiano: I hope it was great — Chris and Dan, thanks again for that excellent presentation and discussion today, as well as Coronis Health for sponsoring today’s webinar.

And to our audience members, thank you for joining us today, and we hope you have a wonderful rest of your afternoon.

Chris Martin: Thanks, Cameron.

Dan Douglas: Thank you. Bye, guys.