This article is initially available on our podcast. Click here to listen.

We’ve done podcasts about more advanced aspects of denials management. We’ve even done a bit of denials management 101 in a recent podcast.

What are your denials management processes?

One of the things, though, something even as simple as denials routing. For instance, where claims are sent to the correct department within the organization. So, it depends upon what type of denial is received. Invariably, it is predicated upon being able to get access to the denials data. Again, it depends on how sophisticated you are in some systems: Whether you’re in a large organization or have a separate denials management system.

In the absence of that, if you’re using electronic medical records, Epic or some of the effective EMR systems (if you’re a hospital-affiliated practice), laboratory information systems, or radiology information systems; many of these systems do not give you access to the denials code data and descriptions so that you can run your analysis.

How do you source your denials management data?

If you don’t have that information, what can you do to get it? To do anything with denials, you have to have that information. Without data, you can’t analyze anything. You can’t benchmark, and you can’t baseline your performance. Also, you can’t make improvements, nor can you track improvements. You can’t quantify improvements. You really can’t do a lot without the data. Of course, you can’t route claims to the appropriate department if you can’t quantify the improvement, just fundamental workflow improvement that you want to do with denials. Of course, you can’t see how bad you are relative to other organizations.

Are your current billing systems effective?

Consider this for those of you that can’t get this from your billing system. Perhaps, there are even scenarios in which you’re getting some paper EOBs; some include denials. How can you deal with this? You may have to change some of your operational processes. For example, if you have paper coming in, you may want to consider routing all of the paper denials to payment posting rather than collectors. Thus, it depends on how your organization is set up.

In many organizations, collectors, if they’re paper, may enter that denial information or decide as they’re entering that information what to do with that claim. There’s sort of a multi-part step process that collectors engage in, where they’re looking at the EOB and determining what to do, and then maybe even taking some action directly with that all in one sitting. That may not be particularly productive if you want to run an analysis off of it.

Are manual processes getting in the way?

You could have collectors enter them and work them individually, but then you essentially lose the benefit of routing them to the best department, as we discussed in another module. If it’s a coding issue, you want to route that to the coding department. If the patient’s insurance has been termed, you want to route it to patient registration. Or if it’s a write-off, then to payment posting. It might seem more efficient to have collectors enter the information from the EOB and then work the claim all in one sitting, but then you’re essentially using collectors as data entry people. We don’t think that’s the best utilization for them.

They’re typically more expensive and better trained, and more experienced than simply payment posters in the hierarchy in most organizations. Again, no judgment to anybody in any particular department. But also, collectors typically are not coders. Some of them, particularly the better collectors or sort of level two or three that do appeals and things like that, frequently do problem-solving and research. But again, they’re not coders. They’re not data entry people and more. So that’s one possibility.

What about clearinghouses?

If you need to get data from a clearinghouse, for example, to get your ERAs for denials because that’s the only way you’re going to be able to access that information, that’s one other possibility. Most clearinghouses will give you access to the areas one way or another. It’s possible they can run a report showing all of your denials and denials codes. Great if you can use that, access it, download it. If not, then you may be able to access the actual individual or aggregate ERA files themselves. Those are the 835 files.

If you get those files, rather than look at all of them individually one at a time and try to enter the data from those 835s into a spreadsheet manually, you could, of course, do something a little bit more sophisticated and create a process to extract the data from those ERAs. We’ve built a system to load ERAs into a flat-file format and remove all that information.

I’m sure other people have done this as well. Of course, you can contact us if you want to use that. Otherwise, if you’re going to build it yourself, you can do that. Again, the 835 format doesn’t change very often. It’s pretty standard. In addition, it’s very slow-moving. Further, the ANSI X12 formats are a very slow-moving ship.

Use basic Excel for specific denials management scenarios

Even if you don’t want to build an application to do that, you can do it in Excel. You can take an ERA or an 835 file, and you can essentially copy and paste it into one giant file. Now, it’s very manual labor-intensive. Or you can take large bunches of them at a time. Essentially, you can use a CSV ERA Import Wizard in Excel to extract the information and load those into the separate fields or the separate columns from the 835 files into Excel. It might take a little bit of time and a little bit of playing with this to get it right, but the delimiter there in terms of the fields is a double asterisk (**).

Nonetheless, if you use a star as a delimiter for that file, then even the Excel Import Wizard will be able to distinguish between those different fields, and it will separate them into the columns so that you can see a patient name, insurance, charge them out. All those things are divided into separate appropriate columns, and that works pretty well. Again, it might take a little bit of tweaking. It’s a little bit more labor-intensive than actually having a system that completely automates it. But again, it’s something you can do.

If you ever want to get a developer to help you with something like this, you can always find somebody on a job board or one of the contract sites like Upwork. They can even sort of add a little bit of automation to that. Again, we don’t suggest doing all of that if you’re trying to do this at scale. Why? Because systems have been created to do that. Reinventing the wheel is undoubtedly more expensive than buying it from somebody like ourselves. Just know that those kinds of things are available. You can access that data.

To summarize

Therefore, going back to denials management and the most important thing. The most crucial aspect is having access to the data. So it would help if you had to get access to those specific denial codes and, ideally, the descriptions and parse that information out.