As the former Administrative Director of Revenue Integrity for Bon Secours Health System (now Bon Secours Mercy), Becky Crytser, MS, RN, CHRI, CPC lead a team tasked with denial prevention.  They were looking for solutions to help mitigate denials upfront and did not interfere with the clinical and operational excellence. Here’s her story about how Effy Healthcare's collaborative process approached the problem from an entirely new perspective and empowered her team to overcome authorization denials.

 

I’m sure many of you can relate to this situation:

You KNOW what your denials are and why they are happening.

The problem is, how can the issue be fixed and prevented from happening again?

And, how can you find a solution that will work with your existing systems and minimize disruptions, so there isn’t the complication and cost of working with new types of claims software?

At Bon Secours Health System, my colleagues and I had been meeting with vendors for several months trying to solve specific issues involving treatment authorization in our Outpatient Infusion Center. We already had a robust operating system (EPIC) and some analytic tools that were a significant investment, so implementing and shouldering the cost of yet another claims management system was not appealing! However, we knew we had maximized the functionality of the tools we already had.

So, in meeting after meeting, vendors came in and told us what their product could do to respond to our denial challenge. They described workflow buckets, advanced scrubbing and claims analysis systems, all viable solutions, but we had those already. We couldn’t see any of the new solutions making a significant impact on the authorization denials' source – last-minute deviations to plans of care arising from patient evaluations.

Then, one vendor came through our doors suggesting an entirely different strategy and listened to our team of experts and said, “We can do that.” That organization was Effy Healthcare (EFFY).

Rather than having a ‘packaged’ solution like so many other systems, EFFY suggested something new: using proven technology – RAID Healthcare Business Assurance (RAID) – to create an ‘umbrella’ over our existing systems that would help us fill in the operational gaps causing denials. An alarm would be triggered anytime RAID detected an identified denial circumstance – making it possible for us to prevent denials before they happened. We decided to go for it!

Developing what we needed

One of the first things I noticed about EFFY’s approach is that they really listened to our team and wanted to get into our existing workflows and systems' nitty-gritty. Together, we mapped our claims processes and examined everything involved in our information flow from start to finish. As we pinpointed where the alarms would be placed, EFFY made sure they got the complete picture by talking to all the teams that touched relevant claim information – from the front desk, to clinicians, to billers. They left no stone unturned by asking thoughtful questions about documentation, procedures, payers, and even performance feedback teams had gotten in the past.

In a relatively short amount of time, we knew exactly where our alarms had to go. Together, we decided on seven rules that would serve as triggers such as no authorization, authorization period, number of services, and usage exceeded. Since the alarms happen in real-time, staff would have an opportunity to take corrective action before a claim was generated.

After testing the system with historical data, we were ready to go live.

Rapid decrease in denials with a quick return on investment

We were delighted by the results when EFFY and RAID worked on our live system. Within a few months, our back-end processes were streamlined. We no longer had inadequate or missing documentation to support medical necessity. We saw an elimination of denials and a drop in our A/R days because we were sending in clean claims!

The easy-to-use dashboard and comprehensive reporting made updating our C-suite effortless and demonstrating return on investment a breeze. Our operational teams used RAID to look for denial trends, analyze performance against benchmarks, and identify educational opportunities. We were able to fine-tune the system as we moved forward and identify many other areas that it could impact.

Ongoing support solved additional denial challenges

We were very excited about RAID’s initial success, and soon understood the extensive potential of the technology. As EFFY’s team continued to provide support, they educated us on how to make new rules where we needed them – empowering our teams to quickly and easily adapt RAID to ever-changing regulations and denial issues. 

In a nutshell, EFFY and RAID did what they promised and much more! Thanks to RAID’s flexibility and accuracy we were able to focus on where are problems were, resulting in:

  • A decrease in A/R days and time and labor saving for follow-up teams, due to our increased clean and accurate claims.
  • Millions of dollars in captured revenue that would previously have been authorization denial write-offs.

I highly encourage anyone experiencing stubborn denials to explore what EFFY has to offer; it bridges the gap between what your revenue cycle is doing and what it needs to do.

Interested in learning more about what EFFY and RAID can do for your organization? Becky would be happy to speak with you. She was so impressed with the results for Bon Secours Mercy that she joined EFFY’s team as Senior Clinical Advisor and Revenue Integrity Coordinator. She can be reached at [email protected].

About EFFY Healthcare

Effy is a software and solutions house, with footprint in multiple markets, focused on improving efficiency in the healthcare industry through technology and driven to produce measurable results through RAID® Healthcare platform, a powerful actionable analytics software solution that addresses effectively all business assurance requirements: revenue, clinical, quality and operational to improve performance throughout healthcare organizations.

EFFY empowers hospitals, hospital systems and Integrated Delivery Networks (IDNs) to retrieve, review and compare massive amounts of operational, clinical and financial data across their total enterprise -- no matter the size, data incompatibility or platform complexity. Using customizable, exception-based triggers to identify deviations from norms, users can reduce errors and denials, improve efficiency and productivity, meet compliance requirements, and ensure financial viability.

About Becky Crytser and Revenue Integrity PRN, LLC

Becky Crytser MS, RN, CHRI, CPC is also the creator and founder of Revenue Integrity PRN, LLC. Her teams’ mission is to “Bridge the gap between mission and margin.” Her combined years of experience as a nurse auditor and leader of a large health system’s revenue integrity team makes her uniquely qualified to help organizations streamline both provider and biller workflows to maximize revenue while providing outstanding patient care. Learn more about Revenue Integrity PRN by visiting its LinkedIN Company Page.