Streamlining Orthopedic Hospital Denials by 98% reducing denials with eClinicalWorks expertise - here's how?

The Challenge

Dr. Mona Gonzalez is a well experienced orthopedic surgeon, owns and operates a full-scale orthopedic super- specialty hospital, “OrthoGen Care” with other 6 doctors in the sub-specialties including: spine surgery, physiatry, orthopedic oncology, orthopedic traumatology, joint reconstruction and arthroscopy, and sport medicine. Most of them have at least a decade of experience in their specialty. Despite this, they are encountering copious denials which put them in melancholy.

Solution

BillingParadise always loves to espouse new technologies and modern business matrices. Our engagement and Dr. Mona’s consecutive click on the “Pinterest” has become the game changing event in OrthoGen Care Hospital. Yes! It was a casual click on our link which made her make a call to us. Her voice was feeble and her words were unsure. We just challenged her that we could mitigate her denials up to 98% and made her eyebrows rise on a continuous talk. On our conversation she had understood that we are a standalone denial management company.

The Retro Analysis

We have started our scrutiny right from the bottom to boost the bottom line of their practice:

External reason for denial

At the outset, we had compiled the reports of denied claims and started sorting out the payer-edge reasons for claim denials. Then, we had gone for segregation of the denials as per the payer’s reason.

Type Of Denial

Subsequently, the denial type was analyzed which enabled further segregation of the denials so that appropriate remedial action can be taken.

Internal reasons for denial

The payers’ reasons for the denial would not be useful in detecting the deeply enrooted etiological factor for claim contamination and denial. Thus, we adjudicated that an internal review must be made for correcting the denials.

Coder

We found that more than 70 percent of the denials were due to incorrect codes.

Workflow

A discontinuous workflow had lead to the delay in submission, claim logging, etc. This accounted for 4 percent of the claim denials.

eClinicalWorks EHR

Though the eClinicalWorks EHR was very much feasible with their practice, the in-house users of the EHR were found to be less EHR-savvy and that is the rationale behind 10 percent denials.

Documentation

Improper documentation of the patient data and clinical data right from the appointment scheduling, encounter data creation, wrong charge entry, has lead to 16 percent of the claim denials.

Next – The Phased Emancipation

Once the scrutiny is over, we had set the roadmap to obliterate all the denials in a step-by-step manner.

1. The denials were segregated according to the category:

• Hard/ soft denial
• Denial that requires attachment
• Denial that needs appeal
• Denial tagged to the respective faulty process

2. Remedial action plan was formulated according to the denial category – with time, staffs and goal set in a streamlined workflow.

3. Troubleshooting was done before the commencement of the workflow to thwart any interruption.

4. Quality check was done on each step of the denial management process.

5. Finally, the erroneous claim components were peer-reviewed and the compilation of claim and supplementary documents were done.

Result

We have made a salubrious denial management through the following features:

Conclusion

After 90 days period, we have presented the denial report to Dr. Mona, like a clean slate with about 98.4% denials effectively managed. Dr. Mona was amazed and said, “It is incredible for me that my practice has achieved such a high reimbursement and you really jumped into the play like a knight in shining armor. Thank You BillingParadise!