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Denials Manager Position Integrates case Management into the revenue cycle
By Arlene Holmes, RN As national initiatives and regulatory programs designed to recover costs continue to challenge acute care facilities nationwide, many organizations have recognized the importance of a position specifically focused on denials management and appeals coordination. This article examines the Denials Manager position created in one organizations Department of case Management to address the specific issues related to denials and the revenue cycle, and its impact on the organization as well as the overall care process. BAcKGrOUND

In 2008, the case management team at Tri-City Medical Center (Tri-City) in Oceanside, CA, realized additional resources were needed in order to delve deeper into denials. The party formerly responsible for denials was the organizations senior-most case manager, serving the hospital for more than 35 years. She was solely responsible for a busy medical-surgical floor and oversaw the organizations denials management. This individual managed the facilitys denials operations well; however, her other obligations and broad scope of responsibility limited the time she could devote to growth and improvement based upon her denial findings and data analyses. Therefore, Tri-Citys case managers wished to develop and expand the organizations denials focus so that it would become a teaching tool as well as an effective means of identifying opportunities for improvement. In order to accomplish this task, the organization implemented the Case Management Denials Manager position. At some organizations a denials position is located in the finance department. The decision to place the Denials Manager within the organizations case management department was based largely on the clinical nature of the position. Though other types of non-clinical denials often arise, the majority of the issues the Denials Manager addresses are clinical issues.

TO DOwNLOAD TrI-cITYS DENIALS MANAGEr JOB DEScrIPTION, cLIcK hErE.

(http://www.acmaweb.org/forms/ RevenueDenialsPositionJobDescription.pdf)

At Tri-City, the Denials Manager serves as a liaison between the hospital and the payor source. These payor sources include Medicare, private insurance companies and the Centers for Medicare & Medicaid Services (CMS). This individual manages and addresses denied cases based on the rules and guidelines associated with each payor. The Denials Manager is responsible for performing retrospective medical record chart reviews, and applies specific criteria to each day of the stay to determine medical necessity and level of care. The Denials Manager functions as a resource and point of contact to various departments involved in the review process, thus requiring a strong collaborative approach. This individual works with the business, finance and medical records departments to coordinate CMS regulations such as those incurred by the Recovery Audit Contractor (RAC) program, Medicare, private insurance requirements and governmental standards. The Denials

FUNcTION AND rOLE

Manager also works closely with the organizations Director of Case Management to provide case management performance indicators. At Tri-City, this role supports the Utilization Review (UR) function of the hospital-wide committee, and works closely with the Medical Director of Utilization Review, who conducts secondary reviews, makes telephonic appeals to insurance payors, educates medical staff and provides oversight of UR functions. When a denial is received, the Denials Manager determines whether the denial could have been prevented, or if the denial is unwarranted and needs to be appealed. Those involved in the care of the patient are notified in writing and by individual discussion. For example, once a denial is received, the Denials Manager sends a letter to the case manager involved in discharge planning for that patient. This letter provides a brief explanation and is accompanied by the actual denial. Once the letter has been delivered to the nurse, he or she is given the opportunity to discuss the case and provide feedback to the Denials Manager. This allows the nurse to provide valuable input which may be useful if the Denials Manager decides to appeal the denial. Although the Denials Manager tracks the root cause of each denial, the information is not presented to the case manager as a disciplinary action rather, the denial is a teaching tool to prevent further occurrences. Similarly, letters are also distributed to the organizations ED case managers and attending physicians. Tri-City employs two ED case managers who provide ED coverage 12 hours a day, 7 days a week. These individuals serve as the facilitys gatekeepers to admissions by reviewing each admission and determining whether to classify the patient as inpatient or observation and the appropriate level of care. The ED case managers meet with the organizations hospitalists twice a week. When a denial occurs, the Denials Manager writes a letter for the case manager responsible for the patient and a letter for the attending physician and leaves it in his or her mailbox. The process of mailing the letter rather than delivering it personally is intentional, and is done so that the party receiving the letter has time to review it and examine the continued on page 9

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Denials Manager Position Integrates case Management into the revenue cycle (continued from page 8)

denial rather than react automatically. The letter includes a designated area where the physician or case manager is asked to respond to the denial and provide any information or feedback, which may help in the denial process or may also aid in identifying a component of the documentation that may have been overlooked. Again, this process is in no way meant to be punitive. Its design serves as a learning opportunity for both the physician and the case manager in hopes of increasing collaboration between the two parties, so that when they meet each week they can discuss denials and follow-up strategies.

payors, private payors, cash uninsured and third party liability. This opportunity for interaction is essential as it allows the parties involved to establish relationships. Recognition is a critical component to the working relationship as the Denials Manager is constantly in contact with both via email and telephone

The individual selected to fill the Denials Manager position must have proven experience in both clinical practice and financial management. Qualifications one should consider when selecting a Denials Manager include: 1. Current RN license 2. Three or more years of experience in case management and utilization review 3. Knowledge of a specific criteria set 4. Knowledge of Medicare Requirements and the RAC program 5. Competency in writing and grammar in order to compose appeal letters 6. Proficiency in Microsoft Excel

QUALIFIcATIONS

The Denials Manager position is a truly collaborative role. It is imperative for an organizations finance and case management departments to frequently interact and establish a positive rapport.
various departments. At Tri-City, experience has proven such departments are much more responsive to requests and inquiries when they have some familiarity with the individual with whom they are speaking.

As part of a project on the revenue cycle, the Denials Manager walked through the revenue cycle with an employee who represented each department involved. The Denials Manager was essentially escorted throughout the facility to learn the necessary steps in order for a bill to move from point A to point B. This not only provided her with a visual familiarity of each aspect of the cycle, but it also allowed her to gain a more complete understanding of each individuals role in the process as they described their function and day-to-day activity. The tour began with access management and ED registration (at Tri-City Medical Center these entities are not co-located) and then progressed throughout the hospital. Stops on the tour included the insurance verification and medical records departments. The Denials Manager met each individual in the respective departments, observed their processes and asked questions. Finally, the tour concluded with a stop at the organizations billing department, where those involved in collections were introduced as well as the organizations Revenue Cycle Manager and the individual responsible for Charge Master. This visit demonstrated the division of labor in terms of governmental

INTErAcTIVE OrIENTATION

Moreover, the Denials Manager position is a truly collaborative role. It is imperative for an organizations finance and case management departments to frequently interact and establish a positive rapport. This enables both parties to understand each others role and showcases how a collaborative approach can serve to decrease accounts receivable days (A/R Days) and increase revenue recovery. In some organizations the billing department is housed offsite. With such distance separating the billing department and case management, building positive and necessary relationships between the two parties is often difficult. At Tri-City, the billing department is located on the organizations campus. This structure provides the Denials Manager with a great deal of influence within the billing department. The Director of Case Management regularly attends revenue cycle meetings, which are held every other week, and he discusses areas of concern and improvement with the organizations revenue cycle representatives. The Director of Case Managements involvement in these meetings gives case management an opportunity to submit input into the process and voice concerns. Furthermore, the Denials Managers involvement provides the organizations case management team with valuable education to the inner workings of the revenue cycle. Additionally, Tri-City Medical Centers Chief Financial Officer chairs each meeting, allowing the Denials Manager an opportunity to become familiar with this key decision maker. continued on page 10

A cOLLABOrATIVE APPrOAch TO DENIALS MANAGEMENT

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Denials Manager Position Integrates case Management into the revenue cycle (continued from page 9)

As an organization involved in the RAC demonstration project, Tri-Citys leadership is keenly aware of the processes and time commitment required of case management. Designating an individual within case management, such as a Denials Manager, to facilitate appeals and address issues related to the RAC program is a valuable addition to any organization. Many hospitals can attest to the amount of time and resources their facility has invested in addressing and preparing for RAC-related issues and audits. Unfortunately there are more auditors and regulatory issues looming on the horizon for U.S. hospitals, and the Denials Manager role will be critical in managing these issues and challenges. In regards specifically to the RAC program, Tri-Citys Denials Manager is responsible for tracking and assisting with appeals. Appeal writing alone is a time-consuming process for case managers but with the addition of a Denials Manager this responsibility can be alleviated. Formerly, Tri-Citys physician advisor (PA) was responsible for patient appeals. This process entailed the PA dictating the appeals into a tape recorder, and then the organizations case managers were tasked with transcribing the appeals. The Denials Manager has since assumed the role of expert appeal writer, creating a more efficient system and eliminating unnecessary work processes.

rAc-rEADY

Another benefit to housing the Denials Manager position within case management is that it provides a pathway to staff education. One of the greatest side effects of creating a denials management position is the interaction with various parties throughout the revenue cycle, which allows him or her to share valuable knowledge with fellow case managers pertaining to their daily practice and utilization review functions. In this regard , the Denials Managers work has served as a form of wake-up call to the organizations case management department allowing them to identify and address key areas of improvement. At each case management staff meeting, Tri-Citys Denials Manager provides a general review of some recent denials. She discusses the root causes of the denials as well as pertinent questions regarding the denial such as: Was the denial preventable in any way? Was this patient ready for discharge? Was case management responsible for the delay in the patients discharge? Was the patient a Medicaid patient who should have gone on the 10 bed call list to receive payment for administrative days? Designating an individual to oversee denials also allows an organization to perform in depth root cause analyses and studies

BENEFITS AND OUTcOMES

functions that are often difficult to carry out with limited resources and competing obligations. The positions creation has increased awareness of denials and its correlation with the revenue cycle within the organization. The education provided to case management staff and other practitioners by the Denials Manager has provided these individuals with a back end vantage point of the revenue cycle, which allows them to equate both cost savings and lost revenue to their daily practice. At Tri-City implementing the Denials Manager position has elevated case managements reputation within the organization and increased its visibility. Through the efforts of the Denials Manager, many individuals recognize case managers are essential professionals in the continuum of care and their role is very comprehensive and requires a thorough understanding of financial variables as well as clinical competency. As previously mentioned, implementing a position tasked with the oversight of denial management allows an organization to thoroughly analyze data and findings and pursue opportunities for improvement. Creating a denials management position allows the organization to be proactive rather than reactive shifting the focus from addressing denials as they occur to prevention of denials. For example, at Tri-City, patients in need of a particular service on a weekend or holiday were often required to wait for the service to be performed until the next business day. The commercial payor would then often deny the day as a result. Through Tri-Citys tracking program, the Denials Manager was able to produce reports detailing such avoidable days, and she in turn provided this data to department leaders. The Denials Manager proposed that if certain services were offered seven days a week, denials would be prevented and revenue could be recovered. With this data, a cost benefit analysis was performed and ultimately the decision was made to offer some diagnostic services every day. The Denials Managers ability to analyze denials and produce relevant patient data drove this critical improvement process. The outcomes and benefits produced as a result of implementing the Denials Manager position are evident. The institution of this role improved current practices, increased collaboration and provided valuable education to a number of practitioners throughout the organization. These improvements ultimately translate into a more efficient care process.

Arlene Holmes, RN, has been the Denials Manager at Tri-City Medical Center since 2009 and has worked as a case manager for 10 years. She earned her associate degree in nursing from Los Angeles Valley College and her BA in English from the University of California, Berkeley. She has been a registered nurse for 36 years and has worked in a variety of health care settings during this time including hospitals, home care, outpatient clinics and schools.

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