RIGOROUSLY APPEALING CLINICAL DENIALSYields $7 Million Plus for US Healthcare Leader

Overview When insurers and other payers decline to cover patient costs for medical treatments, the denials can severely impact financial performance. Many healthcare organizations resign themselves to writing off losses—potentially millions of dollars annually—due to inexperienced resources, unfamiliarity with payer-specific criteria and lack of standard processes. Additional reasons for not appealing include ineffective clinical documentation, inappropriate management of the level of patient care and reactive/delayed practices for communicating with payers.

A large US healthcare organization sought help from Accenture to pursue two goals: (1) one-time recovery of millions of dollars in backlogged cases; and (2) establishing better practices for the prevention of denials, appealing denials and more robust/proactive tracking and reporting of denial root causes.

Accenture and the client worked together to exceed the initial recovery goal of $2.1 million by a large margin. In roughly six months, the project team recouped more than three times the initial goal: $6.7 million.

With appeals continuing to accrue, a second wave of the project widened the scope and the gains ultimately exceeded $7 million as of May 2017. The scope expansion included additional accounts as well as the backlog of open denials, incoming care-management denials and previously written-off accounts from a recently acquired facility.

This organization operates several hospitals, nearly 20 urgent-care centers and almost 100 physician practice locations in the southern United States. More than a century after its founding, the not-for-profit serves nearly 2 million patients and is a leader in cancer care, treatment of heart disease and organ transplantation.

When insurers and other payers decline to cover the costs of medical treatments, the denials can severely undermine financial performance. Varying standards and procedures required by payers intensify the complexity of sorting through all of the documentation and submitting persuasive appeals for reimbursement.

Many healthcare organizations with understaffed back offices revert to writing off denials as losses—millions of dollars annually for some organizations—due to a lack of resources and expertise in mounting successful appeals. This client took a different tack and sought help from Accenture, which had been working with the not-for-profit on initiatives to enhance care management and financial performance.

Launched in October 2016, team leaders targeted a yield of $2.1 million that represented a 20 percent improvement over the established baseline of recouping funds from outstanding clinical denials. Accenture outlined a two-pronged approach: (1) recovery of millions of dollars in cases since October 2015, and (2) establishing better practices for appeals.

CLIENT PROFILE

OPPORTUNITY

SOLUTION

Accenture immediately set out to reduce the load of open accounts and to recoup funds, focusing first on clinical denials exceeding $5,000. To succeed, team members first needed a thorough understanding of the requirements established by the region’s major insurers and payers. Members of the project team reviewed the cases, and called payer organizations to clarify reasons for denials and terms for payment.

Accenture reviewed medical records and examined the details of patient journeys:

• When admitted and why?

• What care was provided on each day?

• Did the care provided meet medical-necessity criteria?

• Did the clinical stay warrant admission based on the medical presentation of the patient upon admission and continued signs and symptoms?

• How many inpatient days?

• What were the discharge details?

ONE-TIME RECOVERY.1

After reviewing clinical documentation associated with patient stays, Accenture completed retrospective reviews using clinical-care guidelines (e.g. InterQual, Milliman), collected additional documentation (e.g. office visit notes, physician letters of medical necessity, previous visit documentation) and/or clinical research. Accenture then developed detailed appeal or reconsideration letters, outlining the reason for the appeal, the patient’s history, reason for admission, and a detailed review of care provided, explaining why it was medically necessary.

As appropriate, each appeal letter included references to clinical-care guidelines associated with the patient’s symptoms and, in some

instances, included peer-reviewed articles to support the appeal. Attached with each letter were key pieces of the electronic health record (EHR) as supporting evidence (e.g. history and physical, discharge summary, procedure notes, progress notes).

After receipt of an appeal or a request for reconsideration, it typically takes payers from one to three months to respond. Accenture team members were diligent about following up: tracking and monitoring accounts weekly, regularly calling payers to verify appeals had been received and routed appropriately, and inquiring when to expect a response.

Payment is frequently denied for reasons related to a lack of proper authorization, care being provided at inappropriate levels, medical necessity for treatment not well substantiated, and procedures and/or products deemed experimental and un-warranted.

By examining hundreds of cases and tracking trends, Accenture identified root causes for clinical denials. At the front end, Accenture advised staff on making better use of clinical decision-support software, completing reviews in a timelier manner, strengthening documentation in EHRs, proactively managing the patient’s

level of care and length of stay, and leveraging technology to enable automated processes, real-time tracking and reporting.

For the back-office team handling appeals, Accenture provided guidelines for prioritizing cases, using technology and templates to guide users in mounting persuasive cases, and improving work queues to accelerate progress. Accenture provided one-on-one and group training sessions to help client staff adopt a more aggressive attitude to recover funds. Additionally, Accenture offered guidance on implementing a governance framework for management of clinical denials, coupled with guidance on robust tracking and reporting of denials, and associated root causes.

LONG-TERM IMPROVEMENT STRATEGY. 2

Results The project team greatly exceeded the initial target of $2.1 million. In roughly six months, the team recovered more than three times the goal: $6.7M. In some instances, Accenture successfully appealed cases denied more than once and with accounts that had been written off by the client.

The gain topped the $7 million mark as of May 1, 2017, and the scope of the initiative continued to expand due to the recent acquisition of another facility with a backlog of denials.

“Our mindset is ‘everything is appealable’,” explains David Balderson, senior manager with Accenture Health. “Rather than looking for only the low-hanging fruit, we harvest the whole tree. We understand the documentation required, and our leading practices—along with templates and communication strategies—help our healthcare clients recoup funds denied by payers.”

In addition to the clinical denials program, Accenture is working with the client on multiple fronts to transform care management. Accenture is assisting with assessments made in emergency departments, suggesting ways to reduce excess days in care, streamlining discharge procedures, and centralizing functions and processes across facilities in the expanding healthcare network.

3x the Goal

Our mindset is ‘everything is appealable’, rather than looking for only the low-hanging fruit, we harvest the whole tree.” -DAVID BALDERSON, Senior Manger, Accenture Health

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$2.1M

$6.7M

1 month 6 months

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