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Streamline the denials process

Patient Access Weekly Advisor, October 31, 2007

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West Virginia University Hospital (WVUH) in Morgantown had a way of tracking and managing denials that resembled a game of scavenger hunt.

To help streamline denials and organize an official policy, a multidisciplinary team consisting of directors from case management, patient access, finance, and the executive suite mapped out an entirely new denial management protocol. The first plan of action was to designate centralized headquarters for all denials coming through the system, says Christy Whetsell, BSB, RN, MBA, director of care management at WVUH.

"The next crucial step we took was to help define all the different types of denials and assign who would be responsible for each type," says Whetsell.

After establishing key contacts with each of the payers and adequately getting the message out about how and where to send denial notices, Whetsell and the interdisciplinary team focused on the internal steps of denial management.

A centralized electronic database was created, allowing anyone involved in the denials process access to information about any denial, any time. Case management checks the database daily, monitors start and end dates, and tracks the response activity between the hospital and payers.

Since overhauling its entire denials management program two years ago, the hospital has seen the following improvements:

• Physicians now seeking information related to their denials and actively participating in the appeal process, which leads to stronger appeal letters
• A decreased turnaround time with appeal submissions and financial resolutions
• Overall denial awareness from every healthcare professional involved in patient care

The biggest mark of success, however, is in the hospital's bottom line.

In 2005, before revamping its denials management program, WVUH had a denial reversal rate of 50%, compared to 2007 when 80% of all denials were reversed in the hospital's favor.

"We've improved because of our tracking methods, interdisciplinary collaboration, and relationships with payers," says Whetsell. "If we didn't make these changes, we'd be in the same boat."

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