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If you’re sick of dealing with vague answers and promises, whether it be from a software vendor, a vendor of services like a revenue cycle management company, a billing company, or even an employee who’s running a billing department or something like that, we had a podcast last week where we talked about some of these issues. Today, we’re going to dive a little more deeply into how to solve and deal with those issues.

Quantify your claims

The first thing to do is to get people to commit in writing to what their claims are. If somebody says, “Hey, we’re going to increase your revenue,” have them quantify what that is. They may give you some vague answers, like 5% to 8%. Please put it in writing. So you’re going to increase your revenue 5% to 8%. Then, drill them on, “How are you going to do that? Evaluate those claims. Show me where you’re going to improve by 5% to 8%, and then show me data to back that up for other people you’ve done it for, what you did to improve it, and so on.” 

If they make some claim like a 99% clean claim rate, quantify and get them to describe in writing, “How do you define a clean claim? What’s your definition?” And what do they think your current clean claim rate is? And then track the before and after. Again, dive in and figure out, “Okay, you’re going to promise 99%. What are we doing now? Show me how you’re going to improve that.”

Streamline operations

It would help if you dug into operational processes. It doesn’t matter whether it’s a software vendor. If it’s software for something like practice management and including billing, you need to see the workflow and how it will work out and how it’s going to improve your results.

Let’s say an employee is going to come in and say, “Hey, we’re going to take over your billing department and radically improve it and make it so much better.” Okay, please show me the operational processes that you see currently, map that out, and show me what you’re going to change it to and how that’s going to improve things. If they can’t document those things, then it’s fluff, and it isn’t significant.

In a previous podcast, we talked about this isn’t about external vendors versus in-house, so it’s not outsourced versus insource. This is about, “How do you evaluate when people make vague promises or answers that aren’t committing to anything and not very definitive?” The key is to ask detailed questions, and follow up, and pursue those lines of thought until you hit the end, and keep going and keep digging.

For this last vendor that we had brought up in the previous podcast, we mentioned this giant spreadsheet, and one of the tabs was a denials tab. We asked questions, just picking one of them randomly and saying, “Let’s dive into this,” to see how robust their processes are. It’s not that we cared about denials, particularly, more than something like missing charges or something else. But it would give us insight into, “Do these guys know what they’re doing? Do they have robust processes that back this up?” So we wanted to ask them, “How do you get the data that gets here? What’s the purpose of it? Where is it going? How do you handle it? What do you do with this? What do you do in this kind of situation?”

The denials tab was blank. We were supposed to imagine how impressive this tab would be when it’s filled out. It didn’t do much for us, so we asked them, “What do you do with this tab? What’s the purpose of it? Do you use it to work claims, so your collectors log in every day into this spreadsheet that’s stored in Google Drive, and it’s a shared file that’s updated in real-time? Or is this just sort of like a pretty picture to give to the clients? How do you work denials if this isn’t it if you don’t use this spreadsheet?”

All about denials

When we asked questions like, “How do you work denials?” the answer was, “As they come in.” Okay, well, then we asked the follow-up question, “What does that mean? What does “as they come in” mean?” We got some vague answers. Again, it didn’t make much sense. We said, “Okay, you ignore the old denials that you got 45 days ago, and you work the denials that you received today?” “No, no, no, no, no, we work the older ones.” “Okay. Well, which ones do you work the first?” “The oldest ones.” “Okay.” 

We’d clarify, repeat back what we think we heard, “Every day, your billers log into your system, and they sort denials by date, the oldest denials, and work those denials first?” “Yes.” “Okay, where do they work that from? Where do they get that information to sort them?” “In the EMR,” they said. “So they depend upon the EMR to have the capability to do what we just talked about. What if it doesn’t have a good denials management module?”

Now, take note that they didn’t say something like, “Hey, we’re going to prioritize dollar claims, the highest dollar ones,” or “We are going to prioritize the ones that are most likely to be paid,” or “We’re going to prioritize ones where we can group them and solve one problem that knocks out 500 claims rather than one at a time.” 

Sometimes, what isn’t said is even more important than what is displayed. You can envision a situation, where let’s say, for example, you have an enrollment problem with a particular payer. You solve that problem. That clears 500 claims from the queue as opposed to slogging away one at a time. You want to be doing that and make sure that somebody is influential, that they’re productive in doing that.

We were hoping that they would say that they would do some analysis of denials. They weren’t saying that. We kept trying to lead them to that answer without directly saying it. We weren’t successful in cleaning through the water, but we tried. We even at one point had to say, “Look, we can’t lead you to the water that you’re supposed to drink, but you should be saying something else right now. We can’t tell you what. Is there anything else you want to tell us?” 

The answer was basically, “No.” We were diving and asking, “Okay, how do you get denials out of the system?” And they said, “Well, that’s easy. The EMR can export them.” I said, “Okay, some of them can. Some of them can’t because we’re talking about a detailed export that has a denial code and reason descriptions in a giant spreadsheet along with dates and other fields, and so on. Most systems don’t have that capability. 

On one sheet at best, you might be able to get it from some systems if you export several reports and then combine all that. I want to see how you do that and join all of that data from all these different reports. Then, what do you do when it can’t export that?” They said, “Oh, no, no, it can do that.” I said, “Well, I’m not sure what world you live in, but most systems we’ve encountered don’t have that sophisticated capability. So what do you do then?”

Spot red flags

By the way, note to yourself a red flag. They may not know many systems, or they may have some unrealistic perceptions of what they can do, or they’re not fully disclosing everything when they try to make you believe that “Oh, yeah, these systems can all do this easily.” That is not true.

We asked them then, “Okay, envision a situation where there’s a system because we’ll point you to some that cannot do that. Now, to fill out this denials tab in this spreadsheet, do your employees every day go into every single claim one by one, and copy and paste out the denial code and description, and paste it into a separate spreadsheet? That’s nuts. So how do you do that? What happens if you can’t do it because that’s like a massive waste of labor?”

Again, the point is digging, digging, digging, and we’re not getting good answers. So more and more red flags are coming up. We were also wondering, “What’s the point of exporting all those denials if you’re just working Last In, First Out (LIFO)?” Of course, one of the things they said, even though that was kind of contradictory. Then, we got into other questions about accounts receivable, and they said different things.

Update incoherent summaries

There is no summary of denials that they provide that tells you, “Who are the top payers? What are the top problems of the payer? What are the top procedures where they’re having issues? Are they referring to providers that aren’t sending you information that you need, that you can group, and solve some problem?” So, where’s the problem-solving? Where’s the analysis that says, “Hey, here’s how we’re going to prioritize. Here’s what we’re going to be able to do to knock out a bunch of claims at a time. Here’s what we’re going to do to try to solve and prevent this from happening again in the future”? It was all basically fluff, just something to “show” for the client to let them know what was going on. That’s not really of much value. 

Nobody wants to slog through a sheet with thousands of records in it of denials, especially given that they said that until the claim is resolved and paid, it stays on that spreadsheet. That means you could have months’ worth of denials all in one tab, just detailed records. That’s not beneficial. Nobody wants to look at that information. You need to analyze that and come up with some answers.

Final thought

We’ve already come so far into this subject. We will split this solution part into part three and come back tomorrow and give you more ways to solve this and deal with it.