If you’ve been tuned into the current news in healthcare you’ll know that the proposed $37,000,000,000 (yes, that’s billion dollar) merger between Aetna and Humana recently fell through, and Cigna and Anthem are fighting over a $48,000,000,000 deal. Those heavy hitters of insurance companies set the standards for the rest of the industry, and also may have a direct impact on healthcare organizations’ bottom line.

What the impact will be is yet to be seen, but there are some things that your organization can now do to be proactive, especially regarding denial management and appeal resolution.

Ch-Ch-Changes, Turn and Face the Strange

Payers are looking for ways to save resources, and one way to do that is to change long-standing policies and tighten up on processes. As payers become more consolidated and those practices become more widespread, it starts to make an impact. For instance, as of March 1,  2017, Aetna enacted a new policy: if a first appeal attempt is denied there is no second level appeal option anymore. This means an appeal must be submitted correctly the first time or the claim is not getting paid, and there is largely nothing that can be done if the appeal opportunity is squandered.

Insurance companies aren’t exactly eager to pay what they owe.  Along with the new Aetna appeal policy, payers are also making retroactive authorizations more difficult or impossible to obtain. The complexity of insurance has increased; Medicare had made many revisions to their policies (you know, like that little policy called MACRA), and many payers are denying claims because of the ever dreaded  “missing information” denial—which basically means the claim needs to be more specific.

Pushing Back Against Payers

Does your organization have the staff and time that needs to be devoted reacting to payer changes, and new complicated issues? The only solution is to stay one step ahead and work smarter.

For example, with Aetna, second level appeal attempts may have been eliminated, but there is a smart way around that. Aetna still honors ‘claim reconsiderations.’ Instead of exhausting that one and only appeal attempt, fill out a claim reconsideration form first. It will not count as an appeal, and may get your claim paid—especially if the denial reason was a processing error or a simple fix like a misspelling on the insured’s name.

Ensure that your denial management staff are trained in known payer issues and are working denials correctly the first time. Assign each of your staff their own payer specialty so they have the time to learn known payer issues and what to do to resolve them.

Work efficiently and identify denial trends. Sorting your denied claim inventory by denial type and payer, quickly paints a picture of prominent issues. The next step is to identify a work strategy to resolve them. It’s easier for your employees to stay in gear and focus on similarly denied claims, allowing them to work through a pocket before systematically moving onto the next string of denials.  

Pick your battles; there’s no sense in wasting time and effort on claims that were submitted incorrectly from the outset, such as incorrect place of service, or improper documentation.

As we talk about time efficiency, think about your follow up practices. The standard industry practice is to process claims within 30 to 60 days of receiving the claim, but that 30 day window varies considerably from payer to payer. This is another good reason for your claim follow-up employees to know their payers inside and out. It does no good to continually check on a claim that is still “In process.”

Look at the Big Picture

Once you’ve mastered your payer’s policies, and improved efficiency with your denials, it’s time to measure your success and see where further opportunities for improvement are allowed. For instance, figure out the total percentage of claims submitted versus what percentage was denied, and then break down the specific sources of denials to work on finding solutions for denial prevention (provider, type of service, missing pre-authorization, timely filing, etc.)

The Bottom Line

Payer policy changes can have a lasting impact on your revenue cycle if you are not on top of denial management in your organization. Work efficiently, figure out tips to effectively maneuver payer obstacles, and make sure claims are submitted correctly the first time. Analyze your denial trends and find solutions, or build edits into your system to catch claim issues prior to being submitted to prevent denials. Taking these steps will keep you ahead of payer policy changes and save time, effort, and money.