Adam Gobin presented on Emory Healthcare's denial management process. They applied management engineering techniques like DMAIC to streamline denial workflows through hyper-specialization and centralization. Key steps included defining denial categories, measuring trends through reports, analyzing patterns, improving through standardized workflows, and controlling quality. This led to significant improvements such as reduced write-offs, registration denials, and medical record requests as well as increased payments for aged claims. Lessons included planning resources, stakeholder buy-in, and using standardized reporting for accountability.

1. Adam Gobin
Director, Revenue Management
Emory Healthcare
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
The Power of Hyper-specialization
in Denial Management

2. Conflict of Interest
Adam Gobin, MPH MBA
Has no real or apparent conflicts of interest to report.
© HIMSS 2015

3. Learning Objectives
1. Define denial categories by analyzing thousands of denial codes.
2. Apply management engineering techniques like DMAIC - to be able
to streamline denial management processes.
3. Design the simplest work flow for staff through hyper-specialization of
workflows, through denial centralization.
4. Diagnose the patterns of remit/claim denial codes – to foster both
predictive and prescriptive analytics.
5. Evaluate denial code mapping and categorization on a recurring
basis to ensure no interruption in workflow.

4. Value Step: Savings
Financial/Business, Efficiency, Operational
http://www.himss.org/ValueSuite
30%
26%
45%
32%
Reduced
write-offs
Reduced
registration/
insurance denials
Reduced
Medical records
request denials
Increase in payments for
claims aged greater
than 180 days

5. Organizational Background
Emory Healthcare is the largest health care system in
Georgia and the only health network in the state that
brings together a full range of hospitals, clinics and local
practices
Emory University Hospital – #1 in Atlanta, #1 in Georgia,
Nationally Ranked in 5 Specialties, High Performer in 10
Specialties
Nearly 50% of Atlanta's Top Doctors are at Emory!
Emory Healthcare is the only health system in Georgia to
have hospitals ranked among the top 10 academic
health systems in America for quality and accountability.
University Healthsystem Consortium (UHC) ranked The
Emory Clinic in the top 5 for revenue cycle performance
4 years in a row

6. Administrative Simplification
“Physicians spend a reported 43 minutes per day on average—the
equivalent of three hours per week and nearly three weeks per
year—on interactions with health plans and not on patient care.”
~The Healthcare Imperative: Lowering Costs and Improving Outcomes
“Approximately $332 billion in administrative costs could be saved
over 10 years from simplification efforts."
~The Healthcare Imperative: Lowering Costs and Improving Outcomes

7. Two Fundamental Drivers for Success
Focus Design
“Healthcare expenditures are projected to be approximately $4.6 trillion or
20 percent of GDP by 2017. No other comparably sized, industry segment in
the U.S. has such weak administrative standards, adoption of existing
standards and disjointed, legacy operating platforms.”
~Fidelity National Information Services Inc.
Emory’s
Response:

8. 2015 Forecast: Increased denials and
Delayed Payments
Challenge Observation Impact
Insurance
Exchanges
1. Difficult to identify insurance
exchange members
2. Insurance companies are
sharing resources to connect
with insurance exchange
members
1. Self Pay: Difficult to collect
upfront
2. A/R: Processing claims is
delayed since insurance
exchange members are priority
for insurers
Increased
Medicare
Advantage
Business
1. Medicare Advantage plans
continue to attract
Medicare eligible patients
with greater coverage than
Medicare Part B
2. Large risk of Medicare
Advantage cuts in late 2014-
Early 2015
1. A/R: Medicare Advantage
plans take longer to pay with
the same reimbursement as
traditional Medicare
2. Payment Variance: Providers
are at risk for lowered
reimbursement

9. 2015 Forecast: Increased denials and
Delayed Payments
Challenge Observation Impact
Varying ACA
Interpretation
1. Insurance companies
have different
interpretations of the
ACA Preventive
Services coverage – a
loophole in the act.
1. A/R & Self Pay: Insurers have several
plans and each plan may have several
employer specific benefits – and at each
level, coverage can vary – thus
increasing non-covered denials and
administrative burdens to follow up.
ICD-10
Specificity
1. Insurers turned on ICD-
10 edits in 2014 to
prepare for the original
ICD-10 go-live date:
October 2014
1. A/R: Increased coding denials related to
specificity – insurers are asking for medical
documentation to specify regions for
Radiology scans for example. Whenever
an ICD code is unspecified or not
otherwise specified – physicians have to
show medical records.

10. Denial Management Complexity
Denial
Management
Phone
Calls to
Payers
Web
PortalsPatients
Provider
Offices
Enrollment
Phone
Calls to
Payers
Records

11. Denial Centralization Pitch to the Team

12. Emory’s AR 2.0 – Denial Centralization
Denial Centralization: An asserted effort to centralize and standardize the AR
workflow of denial management, discover root causes across all denial
groups, & engage major stakeholders (vendors, payors or providers) to
increase efficiency.
THE IDEA  Payors & Providers work together for mutual benefits!
Define Denial Codes and Remark Codes.
Measure through daily and weekly pulse reports.
Analyze through concise project charter.
Improve through standard operating procedures.
Control through quality audits and monitoring “Days to Pay”.

13. Committee on Operating Rules for
Information Exchange: Emory’s Integration
• Business Scenarios:
– Scenario #1: Additional Information Required-
Missing/Invalid/Incomplete Documentation.
– Scenario #2: Missing/Invalid/Incomplete Data from Submitted Claim.
– Scenario #3: Billed Service Not Covered by Health Plan.
– Scenario #4: Benefit for Billed Service Not Separately Payable.
Categorizing claim adjustment reason codes (CARCs) and remittance advice
remark codes (RARCs) by groups – using CORE combinations – increases
efficiency of denial follow up and cash turnaround.

14. Define Denial Codes & Remark Codes
Reject Code Reject Reason Category
252 Missing Attachment
Medical
Documentation
Phone calls to
payers
Web portal
claims status
Washington Publishing Company’s Data
Denial
Categorization

15. Measure through pulse reports
Weekly/Monthly Tracking Leads to Key Actionable
Trends and more importantly – Payer/Provider Partnerships
$0.00
$500,000.00
$1,000,000.00
$1,500,000.00
$2,000,000.00
$2,500,000.00
$3,000,000.00
$3,500,000.00
$4,000,000.00
DUPLICATE INFORMATION
NEEDED TO
PROCESS
NON COVERED PRECERT
REFERRAL
PROVIDER
RELATED
REG INS
RELATED
Oct
Nov
Dec
Both a weekly
& monthly
report

16. Emory’s Partnership with its Payers Led to
Significant Process Improvements

17. Analyze through concise project
charters & other PM Tools
Problem
Statement
Identified
Stakeholders
Mapped Current
State
Created Milestones
Measured Results
Transcatheter Aortic Valve Replacement (TAVR Case Study)
Results: 85% decrease in days to pay for TAVR claims

18. Improve through standard operating
procedures
Bundling Denials
Results: 35% decrease in days to pay for bundling related claims

19. Control through quality audits
Twitter Approach to Text
Data or categorical variables
Instagram Approach to
Numerical data
Qualitative Audits Quantitative Audits
• Identify the frequent outcomes chosen
by the AR follow up team and strive for
automation or process improvement
opportunities
• Track quick stats on a weekly basis to
effectively communicate trends and
identify opportunities to streamline

20. Communication of Denial Trends/SOPs
• Emory created an Accounts Receivables Wiki page so that
communication of trends and findings (denial spikes, payment
trends, ) is real-time for all stakeholders across the organization.
Entry Date: 01/10/2015
Author: Adam Gobin
Subject: Incorrect Medicaid Denial (N55 Remark Code)
Impact: $2M – across all clinic specialties
Expected Resolution Date: 01/31/2015
Comments: Medicaid incorrectly denied claims with the
N55 remark code. Emory has re-filed all impacted claims
and expect to receive payments by month’s end.
Example Wiki Update

21. Future of Claims and Remits Analytics

22. Lessons Learned
• CORE Code Combinations = the Denial Centralization concept is born!
– Improving denial management through data analytics and management
engineering techniques.
– Working together to build a foundation for the future!
– 1st attempt for payors & providers working together for mutual benefit
(decreasing overall administrative costs)!
• General Implementation Considerations & Challenges:
– Planning and Resources  reject code & type dictionaries.
– Implementation Considerations/Steps  identifying centralized denial
groups, creating centralized denial teams & members, SOP’s & reporting
(stage summary, days to pay, etc.)
– Challenges & Resolution – stakeholder buy in, setting up systematic
accountability, generalists v. specialists, equivalent reporting.

23. Value Step: Savings
Financial/Business, Efficiency, Operational
• The Emory Clinic leverages a relationship with CAQH – utilizing CORE code
combinations to effectively redefine & centralize denial groups on a
recurring basis.
• The Emory Clinic continues ongoing collaborations with payors,
clearinghouses, & banks to streamline workflows.
• Breeding consistency, transparency, & accountability - denial centralization
has successfully reduced The Emory Clinic’s AR metrics:
– 7-Day Decrease in Total DAR!
– 25.6% Decrease in Registration/Insurance Related Denials!
– 32.15% Decrease in Medical Documentation Denials!
– 30% Increase in >180 aged claims Payments!
– 45.22% Decrease in Monthly Write Offs!
– Predictive v. Reactive Analytics!

24. Questions
Adam Gobin
Director, Revenue Management
@AdamGobin