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January 2017 Medical Oncology News

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The Oncology Denial Management Committee

By Jeremy Hogan and Matt Terry

In today’s healthcare environment, insurance payment amounts are shrinking, operational costs keep rising, preauthorization is expanding, medical necessity within payer policies is changing from day-to-day, billing requirements are becoming more complicated and contract terms are continually tightening.

All of these barriers mean more denied claims at a time when capturing every dollar is necessary to prosper—or even just keep the doors open. One of the best ways to combat an ever-shrinking profit margin is to be proactive by diving into the underlying detail of your denied claims and determining what you as an organization can do to correct existing claim deficiencies. To get started, consider forming an Oncology Denials Management Committee (ODMC). Many hospital organizations have a Denials Management Committee for their entire system; however, it’s important to develop an oncology-specific committee to address the unique issues oncology faces and the high cost per claim.

In developing your ODMC, we recommend inviting leaders from Hospital Information Management (HIM); Patient Financial Services (PFS), including accounts receivable (AR) insurance follow-up; Patient Access; and clinic representation to include nursing, pharmacy and physicians. Involving all aspects of clinical and revenue cycle services will round out the committee with a comprehensive knowledge base, allowing them to truly determine the root cause of a specific issue and provide the most effective, efficient solution. In addition to having this breadth of knowledge, the team can also create institutional or divisional unity around a common goal. For example, if the current goal of the committee is to eliminate denials due to lack of authorization of add-on drugs, the clinic, support and revenue cycle staff will all be aware of the effort and their role in eliminating them. Providing transparent data and creating a thematic goal for the oncology department will inspire staff to work more as a team.

Leadership for the committee is important, as well. Since the team will be made up of leaders, many individuals will naturally try to steer the committee’s course. It’s important to name a chair or leader who does not dictate direction, but instead, allows all members to be heard, keeps minutes, assigns tasks/next steps, keeps the meeting on point and continues to push for progress on each denial issue.

We suggest the ODMC meet weekly at first, then scale back to monthly as issues begin to be resolved. Determining the issues and the order in which they will be resolved is typically less time consuming, so those meetings are shorter. Presenting and discussing the information requires a meeting that’s a bit longer. And finally, determining a solution often requires the longest meeting of all. 

When trying to determine which goal or theme to tackle first, best practice facilities prioritize their denials by dollars and by volume. Correcting the processes that lead to high dollar denials generates revenue. Correcting processes that lead to high volume denials improves efficiency, which in turn allows staff to refocus their efforts in other areas needing attention. At Revenue Cycle Inc., we recommend that the ODMC choose one or two high dollar denial issues and one or two high volume denial issues at a time. Of these, the committee determines the order in which the issues are to be resolved. Data is shared with the committee and after a discussion, the next steps are determined. Make sure that at each meeting tasks such as instituting change or gathering additional information are assigned to team members to accomplish before the next meeting occurs. It’s also important to define success for each denial issue and how it will be measured. If efforts are not measured and shared, teams often become disinterested and lose focus.

Denials can chip away at your bottom line, but they don’t have to. With a dedicated, systematic approach to addressing them, your organization can correct underlying issues and capture revenue that may have been previously written off to bad debt. Having fewer denials will lower your operational costs, too, which also helps your profit margin. Along with yielding financial benefits, the success of your ODMC will help your organization become more transparent and foster a team approach for navigating issues as they arise. To get help developing your own committee, rely on the experts at Revenue Cycle Inc. For more information, please contact us at 512-583-2000 or visit our contact page.