HIF430
Week 5, Assignment 1, Denial Dashboard and Decision Support
Domain VI. Leadership Roles
Subdomain VI.F. Strategic and Organizational Management
VI.F. 7. Facilitate the use of enterprise-wide information assets to support organizational strategies and objectives.
Attach your assignment to the assignment tab. This assignment is worth 10 points.
Here is a thread on the AHIMA Engage site that may be interesting to read before you begin this exercise: https://engage.ahima.org/communities/community-home/digestviewer/viewthread?MessageKey=0f1da818-24cf-49ac-8273-92c433744803&CommunityKey=9b900310-59c0-4a96-90f9-5e6e53d5ba42&tab=digestviewer#bm0f1da818-24cf-49ac-8273-92c433744803#bm6
You are the revenue cycle manager for your hospital. The denials management coordinator provides administration with dashboard information regarding denials monthly. As the revenue cycle manager for the facility, you also receive the same dashboard. The last dashboard received showed small newer accounts were being worked first, while several much older large payer accounts had been languishing behind the small accounts. The CEO of your hospital has demanded a better process for denials management. Right now, there is no control over the way the denials flow into the denials work queue, either by payer or by aging. For those students who have not had exposure to denials, these are the insurance claims that are sent back to the hospital or healthcare organization unpaid due to various issues of medical necessity, upcoding, unbundling and claims that are duplicative. These insurance claims are then individually investigated by a denials section usually within the revenue cycle division, any corrections are provided for billing purposes and/or additional supporting documentation is attached, and the claim refiled. You have decided you want to address your denials by account aging first and then by payer, because one of your payers represents the most money to be recovered of the three in the group and you want the payer with the most money sitting in denials done first in the workflow, then the next, etc., by each aging timeframe. Creating a rules-based workflow will help you create some efficiency in your denials process and get the claims addressed in a more organized way.
Your days post-discharge by which you group your denial claims:
- 0-30
- 31-60
- 61-80
- 81-120
- 150-180
- 180+
The statistics of your recovery by payer averaged per month over the last 8 months:
| Payer | Total Accounts by Payer | Total Money Recovered per Account by Payer |
| Medicare | 6 | $51,835.00 |
| Medicaid | 2 | $14,451.00 |
| Commercial | 4 | $27,147.00 |
Start with a simple goal statement, resulting in an action statement. What are you trying to achieve with this rules-based decision support? You know from the above scenario that you would need to use your databases to get the oldest accounts addressed by the appropriate payer in the order desired. An easy way to do this is to use numbered steps of what actually happens and then begin to populate your data elements. What happens first? From the rules-based statement, create a table like the one below for rules step-wise that shows the data set you would use. Hint: One thing you would need to be able to identify is the age of the account. Be sure to label the algorithm you would use if it is applicable with each step of the workflow you would create.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Here is an example of a clinical algorithm for decision support for mammogram and note you would create something similar, but the data elements highlighted in blue would be different – for example is it important to know gender or age of the patient in the above denials example? No, it would not be important to know gender or age of the patient to whom the account belongs. But, you can see how this rules-based workflow was created from the database containing the clinical and administrative record. Create the same rules-based workflow with a goal and action from information you would obtain specific to accounts of patients.
GOAL: Annual mammogram on all women 50-75 years of age.
| Data Element | Required values | Algorithm (if applic) | When/where data captured |
| Patient age | 50 – 75 | Current date minus DOB | Registration – Pt demographics |
| Patient gender | Female | N/A | Registration – Pt demographics |
| Encounter type | Outpatient | N/A | Registration – Visit type |
| Mammogram result in EMR | Yes / No | N/A | Clinical event – Mammogram posted to EMR |
| Mammogram date | Within 1 year of current date | Current date minus date of last exam | Date of mammogram |
ACTION: IF mammogram missing (result = No)/ overdue (date > 1 yr since last mammogram report) then ORDER mammogram
NOTE: The amounts listed on this assignment for denials totals are provided only for demonstration purposes. In practice, the amounts might be much different.