Custom solution addresses denials dilemma for children’s hospital

For many health care providers, denials—a refusal of carrier payment for services—are a pervasive feature of the revenue cycle. Tracking the where, the when and the why is a daily challenge, but it’s essential to recapture lost revenue.

A children’s hospital client can attest to that. The organization was challenged with consolidating various data streams resulting in hours and hours of report compiling and limited denials analysis. Client leaders knew there had to be a better way. They reached out to RSM US LLP for help and discovered that RSM had a custom solution just right for the organization.

According to the client, there was no easy way to pull data together from their clearinghouse and electronic health record system. Once they did run reports, their computers would time out when they tried to pull something like claim number by medical service type. They were wasting time and didn’t see meaningful results.

After evaluating the organization’s challenges and learning of their specific denials management needs, the RSM team presented a solution that could address their consolidation issues and provide custom reporting.

According to the client, they were excited after seeing RSM’s denial’s solution. It allowed them to get reporting by the payor; on a three-, six- or nine-month basis; by medical service type, and more. This was something they’d never seen before. The solution’s reporting identified denials immediately and saved hours of time.

Delivering the must-haves

In addition, the client needed the denials management tool to identify the specific medical service type information, such as spine patient services. Unfortunately, claims for these types of services all fell under the more general outpatient billing segment in the past. Therefore, the ability to drill down on this granular information to identify actionable insights would be a must-have for the organization’s ability to serve the unique needs of its care population.

Message heard by RSM. A custom-built solution was provided and with one click, the medical service type was revealed.

Meaningful outcomes

It’s now been two years since the implementation of RSM’s denials management solution and according to the client, the hospital has seen meaningful progress.

As for the wasted time formerly spent in data sorting, sifting through spreadsheets and manual report compiling, the client indicated now the organization has time to address more strategic initiatives or do further analysis. For example, a member of the denials team recently examined prior authorizations that on the surface appeared to be a low volume of denials; however, stretched over time, the total of denials was significant. The team member evaluated the issue and identified a simple fix.

According to the client, this was not something they could have done prior to using RSM’s denial management interactive dashboard.