Chart Check Up
Leveraging clinical perspectives for the middle revenue cycle – insights that drive impact. Offering support to keep current on clinical knowledge, coding updates, and industry trends.
Chart Check Up
Hidden Tactics of Healthcare Denials
Dawn Carey, Director of Denials and Appeals at Acuity, joins us to explore the evolving landscape of healthcare claim denials and the tactical responses needed to address them effectively. She reveals how AI, payer tactics, and clinical criteria manipulations are creating unprecedented challenges for healthcare facilities struggling to protect their rightful reimbursements.
• Post-COVID changes in denial patterns with auditors using AI to process unprecedented volumes of claims
• Distinguishing between AI-generated and human-reviewed denials is increasingly difficult
• Prepay denials force hospitals to adjust claims before payment, effectively holding revenue hostage
• Payers create their own clinical criteria for denials, often cherry-picking from established guidelines
• Hospitals must break down departmental silos between contracting, revenue cycle, and CDI teams
• Limiting the number of records payers can review through contracts is an effective mitigation strategy
• Regular meetings with payers, tracking strong cases, and leveraging peer-to-peer reviews help overturn denials
• Acuity's AI solutions include Amplify for chart review and new AI applications for denial management
• Interdepartmental collaboration is crucial for addressing increasingly sophisticated denial tactics
• Facilities using Acuity's integrated physician-coder model experience denial rates under 0.5 percent
Welcome to Chart Checkup clinical perspectives for the middle revenue cycle. This podcast delivers insights that drive impact in healthcare information management, stay current on clinical knowledge, coding updates and industry trends through expert interviews and conversations with Acuity's own physician, cdi and coding leaders. I'd like to introduce our guest for this episode, dawn Carey, director of Denials and Appeals at Acuity. Dawn, welcome to the podcast. I really appreciate you joining us here and, if you would, would you give us a quick rundown of your background?
Speaker 2:Hey, bill, thanks. Yes, my name is Dawn Carey. I am the Director of Denials and Appeals here at Acuity. I'm Keri. I am the Director of Denials and Appeals here at Acuity. I'm an RN for almost 25 years. I began working in CDI in 2016, just before the changeover from ICD-9 to 10. I'm here at Acuity for almost seven years.
Speaker 1:Awesome. We really appreciate you joining us here on the podcast.
Speaker 2:Awesome, we really appreciate you joining us here on the podcast. With that, I was hoping to discuss with you just sort of general trends and denials and then digging into some of the deeper issues there. What are some of your thoughts on den for I would say almost two years, a year and a half at least and then the dynamic changed a little bit, with a trend up to pretty large volumes in denials. The auditing companies changed staffing, they went down to almost nothing and then really roared back with a vengeance.
Speaker 1:A deep vengeance, absolutely. We had talked previously a little bit about bringing AI into the equation now, and it's certainly a hot topic amongst both our colleagues at Acuity but also in the industry in general.
Speaker 2:both our colleagues at Acuity, but also in the industry in general. Yes, the AI some of the auditors I know began using it probably a year ago, probably longer. I'm sure they were developing before that.
Speaker 2:But yeah, that has increased volumes they can use that program or application to review charts and then put out it seems like, like I said earlier, very large volumes of denials and it's kind of hard to tell if they are an AI denial versus a person reviewed. So regarding the AI versus human developed denial, it's difficult sometimes to tell because some of the written or human-developed determinations don't make a lot of sense when you're reading them, or they have nothing. They'll have minimal clinical or coding information, so it's very difficult to determine where they're coming from or where that originated from.
Speaker 1:So it's very difficult to determine where they're coming from or where that originated from. Do you see changes or a future to AI, and where do you feel like it's going to occupy the space here as an ever-increasing tool? I feel sure.
Speaker 2:I do. I think it is going to increase as other auditing companies, the bigger auditing companies, are using it. Some of the smaller ones, I'm sure, aren't able to implement that, but I think that that will grow. It's unfathomable how many denials we're getting now, and I believe a lot of that is partly due to the ability of those companies to use AI and not have to employ people.
Speaker 1:It's certainly an interesting numbers game of getting bang for their buck versus the validity necessarily of a denial.
Speaker 2:So, from a business perspective, the post-COVID offshore outsourcing and AI, that combination has allowed these denials, these volumes, to really, really increase for all the hospitals, all the companies that take care of them.
Speaker 1:That's a really amazing point that I hadn't considered. I think that certainly, having lost a pool of expertise with the layoffs that came with COVID, that's a really interesting idea. I hadn't considered Thinking about prepay versus postpay. Do you have some thoughts on how that's going to play a role in denial trends?
Speaker 2:Yes, Prepay, they were doing that. Auditors had a little repairs, struggled a little bit a few years ago trying to implement the prepay because the hospital defend that claim before they get any payment. They had to work at trying to get that payment plan or process in place and they do have that in place now and those are pretty damaging for the hospitals. Also, it almost forces them. Many of the denials will state in that determination that they must file a new claim. So that forces that hospital to get even part of the payment. They adjust the claim which in a sense says okay, we coded this wrong, despite whether that really was a valid claim clinically. You see that more with the clinical denials, the clinical validation, versus the post pay where they pay the claim and then they take that back, or they pay it and they can't take it back until that determination is or the denial is final.
Speaker 1:Oh wow, it's sort of held hostage there. Considering sort of the clinical criteria trends, have you experienced any thoughts, or do you have any thoughts, I should say, on clinical criteria notifications from payers?
Speaker 2:That is another interesting. It's really not. It's really not interesting, it's awful. But yes, the payers working with the auditors this is another tactic they use. The auditors are able to develop or write their own clinical criteria. They then send that to the payer that they're working with. They get that approved from the MD there, the medical director, and they're allowed to implement that to use to deny claims.
Speaker 2:And we have seen some of their tactics. There are peer-reviewed references where they'll just take pieces of it and a couple of them are CEP3 versus CEP2 or your gold standard for COPD. They'll pull pieces of that out and use that to deny certain things like respiratory failure or sepsis. If they send that to the hospital, they'll send it out as a notification beginning of the year or whenever really I don't think that there's a timeframe but they send that to the facility and if the facility doesn't push back or decline, using that, it gets implemented. And they in some of the peer-to-peers that we go to they say that you know you agreed basically by not responding to that notification of the change in that clinical criteria.
Speaker 1:So again they're stuck the hostage statement you made earlier is very true to meet, if it can ever be met that we're in, but that it's very interesting to gain your insight onto what we'll see as trends and denials, and then also the avenues that are being used in that way. I really appreciate it.
Speaker 2:It's best to be proactive versus reactive and work together with other departments. That's another thing. A lot of these departments are siloed. Contracting is not working with RevCycle or Denials CDI to get feedback. When I began in 2017 in Denials, I kept asking I need to see what the contract says. These denial letters are stating certain things and it was very difficult. They almost protected that information like it was their personal info.
Speaker 2:So, that's something you had to work with your different departments and try to get everybody to work together to see what is happening and what they're trying to hold everybody to. Yeah, and then can you imagine all the different payers. You know you have many different payers trying to look at all that contracting and it can all be different and that's why contracting is a very important part of denials and working together and trying to limit those different criteria.
Speaker 1:Some thoughts on how a facility could mitigate these changes, try and step around some of the requirements or address them in a different sense.
Speaker 2:Yeah, and the couple things that I mentioned about communicating, pulling the different departments together and looking at contracting, looking at your payer notifications who's getting those? Who's taking care of that? Does your denials department, cdi voting? Do they know when those are received and do they get reviewed or agreed upon? Disagreed Contracting is huge.
Speaker 2:Limiting the number of charts an auditor can or a payer can review I know another trend that these payers are using is they're asking for access to the chart and it is easier. The hospital doesn't have to send the medical record. The payer can just go right in and look at that patient chart. Another tactic they're using too are in these prepays. They're looking at prior claims to see if a disorder or condition is present and they'll deny based on if it wasn't. If this is a new condition the patient has, they'll say, well, we didn't see that in their history. They don't have that. That's another tactic they're using.
Speaker 2:But limiting the number of records a payer can review is very helpful. Also, and a lot of facilities don't know they can do that Egregious auditors can be. You know they should meet with the payers. They should meet with their payer reps. They should have monthly meetings with the payers to discuss these changes, any clinical changes they should track.
Speaker 2:And I kind of was going to mention these later. But final cases that are strong, that are upheld, those should be tracked and taken back to the payers to do a root cause and say you know, these are valid cases, you know some patients expire and they still they'll deny sepsis. Sepsis is a very horrific condition with a high mortality rate and you know, to deny something like that is shocking. But yeah, contracting, communicating with the different departments, escalations, take advantage of peer-to-peers, any escalation that your payer offers. Take advantage of peer-to-peers any escalation that your payer offers I would definitely take advantage of. And it is a bit of a more work initially but once somebody gets a flow communicating with the payer and setting up peer-to-peers or these monthly calls, it's very beneficial and I think it does help overturn a lot of the cases.
Speaker 1:That's a great point to make, that bringing the stakeholders to the table and having them sort of meet eye to eye is a great perspective on trying to navigate these waters for especially facilities that are smaller or might struggle with that more.
Speaker 2:That is absolutely true.
Speaker 1:Do you have any more thoughts on what to do with? Do you have any more thoughts on what to do with strong clinical cases that you feel are most hurt by just the volume of denials or the techniques being used?
Speaker 2:the final cases and take those back to the payer, review the case and have them explain how they you know how they're supporting that decision. Another thing that I've noticed too, another tactic that the payers use they have limited the recourse that hospitals have. They're giving one level of appeal. They are taking away peer-to-peer options. One of the payers is calling that they're offering an educational, a courtesy call. I mean, think about that. A hospital is going to have a staff member set up calls for, say, 10 cases, and then they have to have a physician available for the payer to call back at their leisure, which is, you know, not a great scenario for a physician or someone setting up these calls.
Speaker 1:Absolutely. I imagine that's the last thing they want to hear.
Speaker 2:Anything to make it difficult and overwhelm the hospital is their goal. Some of the things that Acuity has developed AI, some AI technology. One is called Amplify, which assists with chart review, query implementation or initiation, and we also use a little bit of AI technology in developing those queries that are specific to the identified clinical diagnosis that needs to be clarified the identified clinical diagnosis that needs to be clarified. And we are also developing an AI application that is assisting with our denials. It's pretty amazing. It is reviewing the denial letter, pulling together what was denied, references that that auditor is using, and it is pulling together a clinical rationale paragraph, which is all the ones that I've reviewed. You know there's very few now. It's been months We've been in development, probably nine months plus, and they look really good.
Speaker 1:Wow, it's exciting to hear especially bringing AI to this side of the fight I think will be an important element the whole industry but that it's especially exciting to be a part of rolling that out that well. I haven't worked at all with the, the denials AI, which I'd love to hear a little bit more about, how you think that that will play out in the future, but that just in using our Amplify technology with some of our current clients one of our major clients, who are rolling it out currently in a big way, and that I'm excited to see the flow of numbers and information that we are able to collect from that and understand how we can better address the AI-based denials, the flood. Essentially, that is coming the other direction and so it's very exciting.
Speaker 2:It is AI's model using physicians and a coder or a DI specialist. Erg integrity specialist is what a DIS is is really, really. That was cutting edge. I thought when I started here at Acuity almost seven years ago, I really wasn't aware of any other company using that model. Now, with our AI chart review and then pulling that in with a denial, it's amazing and it's speeding up our denial reviews. We're only using it in a few clients right now, but yes, it's exciting.
Speaker 1:Really amazing. It's like we're living in the future. I love it.
Speaker 2:The proof in the pudding so far, our denial rates on cases that we find opportunity is very low. It's under one. I think it's under 0.5 percent, and we can pull some numbers in Bill too if we want to add any, but yes, we're doing very well.
Speaker 1:Yeah, yeah, awesome. Well, this has been an incredible discussion, dawn. I really appreciate you joining us on the podcast today. Thank you very, very much. No-transcript or treatment you may receive from your healthcare provider.
