Learn how access to better trend data is affecting CHOC's in-house workflows.
How important is analytics access, whether internal or via a vendor, to hospitals' denials management success?
Terry Closson: "The electronic health record that we have does not have great work lists for us. And so, denials management for us has been incorporated just into the regular workflows for a number of years. However, about a year or so ago, we bought an analytics tool that has been very, very helpful for us. And I'll give you an example of what denials specifically that it found for us that we weren't, you know, working on because it took the system holistically (which we couldn’t do before). Everything goes into this tool. And so, we were able to identify that suddenly one of our prominent payers started denying all of our claims over $50,000. And that's pretty much in a children's hospital, any claim, right? Any inpatient claim over, you know, $50,000 is going to get denied. And it was not coming back with remark codes, so we didn't know why it was being denied. When we would manually follow up with the payer, they would say, ‘oh, we need medical records’ or, ‘oh, we need an itemized bill,’ which is kind of crazy for a $50,000 claim, right? However, this analytics tool has helped us identify that. And so, we then took that tool a little bit further and then put in some automated platforms and artificial intelligence to that so that the day after we sent out the claim, we would then send medical records with them or we would send an itemized bill, entirely separate, so they couldn't deny it without having a more substantial reason. Even though those are not good reasons to be denying a claim in the get-go, you don't need it. For a $50,000 claim, you don't need medical records, right? You don't need an itemized bill, right? But they did. And we never would have found that before had it not all been in one platform.
"And so, we are very, very appreciative of having that tool. As a matter of fact, the follow-up team is no longer using our electronic health record to work their follow-up. They're simply using this analytics tool for us to have all of their workload in there and what the next steps are. And whoever is coming in behind them to work that claim, if it's not getting reworked, it's timed, etcetera. And it's been just wonderful for the team and wonderful for the organization as well. We still have a lot of payer denials and a lot of payer delays, for lack of a better word. But we’re also getting some new ammunition to go back to the payer and say, why are you suddenly denying all these? These are standard claims. They went out clean. There's nothing wrong with them. Without this analytics tool, we probably wouldn't have noticed trends so quickly. So that's been wonderful.”