Creating Wins by Driving Down Denials

Whenever you get a free vaccine, visit your favorite physician, or open a medical bill to see exactly the amount you expected to pay, you can thank someone in your hospital’s billing office. Specifically, someone who handles insurance denials, like Kelly Black, VP of Revenue Cycle, or Sandra Jones, Director, at Novant Health, a four-state integrated health system based in North Carolina.  

Black, Jones, and Novant’s physician billing team may never meet a patient face-to-face. But they work diligently to make sure insurance claims are processed quickly and correctly. For patients, this means fewer billing surprises or unanticipated delays in care. For physicians, it means fewer administrative headaches and more timely compensation.  

Because insurance denials impact both patients and their doctors—determining how much a patient might pay for care, and how much and when a doctor might be paid for their work—managing them is critical to smooth healthcare operations. Data from Centers for Medicare and Medicaid Services (CMS) shows that nearly 1 in 5 insurance claims are denied, usually without a specific reason.  

Addressing the outlier 

Working with insurance denials requires a unique combination of precision and creativity, combined with a passion for solving problems. In 2019, Novant used this problem-solving approach to improve billing efficiency. By implementing specific workqueues for each type of insurance denial, they reduced outstanding denials by 60 percent in six months.  

But one workqueue remained persistently problematic—the so-called “catchall” workqueue of claims that didn’t fit into any of the other categories.  While denials moved through other queues as expected, the catchall queue wouldn’t cooperate. “Our denial strategy was so successful, and there was this one outlier we couldn’t get our arms around. We could either leave it alone and accept that we would have money that was a write-off, or we could invest in fixing it,” said Black. 

Black chose the latter, and already knew a team with the EHR expertise she needed. She’d connected with Tegria’s Revenue Cycle Transformation team at an industry conference months earlier, and touched base periodically to chat through pesky EHR problems. “They established a relationship, asking questions and really trying to understand our culture and the issues we’re trying to solve,” said Black.  

Jones led the Novant and Tegria teams in kicking off the PB Denials Management and Automation Project in November 2021. Thanks to Tegria’s ongoing conversations around Novant’s EHR pain points, the project took flight with a relatively short runway. Tegria’s team—engagement director Cameron Steeples and revenue cycle transformation experts Patrick Kelly, Brandon Cooksey, and Jay Nelson—started working with Novant to uncover and resolve the root cause of their denials problem. 

A culture of curiosity and collaboration 

Right away, Steeples noticed something different about Novant. Compared to organizations with more siloed billing offices, Novant had an open, collaborative culture that fueled the team’s progress. Thanks to a strong relationship between the physician billing office and other key workgroups, like Novant’s central operations team and growth and integration team, questions and small hurdles were cleared before they became roadblocks.  

“From the start, we felt like we were part of the team and it was clear that Novant was willing to partner with us and put their trust in us, even though this work was completely virtual,” said Steeples. “Their culture of collaboration across the organization contributed to the overall success of the project.” 

At Novant, innovation is welcome and big questions are encouraged, said Jones. “Kelly fosters that environment. We’re allowed to dream, to wish, and to say ‘what if?’ I think that’s where a lot of creativity and great ideas come from. It makes us all want to put our heads together to see where we can take something.” 

Although large health systems can struggle with rapid change, Novant welcomes it. According to Jones, embracing change keeps Novant nimble, responsive, and open to new ideas. “Healthcare changes daily. Sometimes it feels like hourly,” she said. “You have to be OK with change and you have to be able to move with it.” 

In the early days of the COVID 19 pandemic, Novant’s physician billing team pivoted to a remote work schedule in just 48 hours without losing momentum. While the rest of the country was trying to transition to telehealth, the team was a step ahead, quickly figuring out how to bill for it. More recently, the team quickly determined how to handle insurance billing for a mobile Monkeypox vaccine unit delivering immunizations in the community.  

From root cause to resolution  

During the PB Denials project, Novant’s collaborative, flexible culture helped Tegria implement quick wins: small shifts to processes or procedures that could make an immediate impact. One such win involved removing unneeded steps from an everyday task to save time for staff. “They observed us, and saw where we could eliminate steps in our process to make things more efficient to cut down on the manual work our team was doing,” said Jones. 

Within a few months, Tegria helped Novant achieve their ultimate goal: uncovering the root cause of their workqueue woes. As a result, Novant decreased their rate of duplicate denials by over 35 percent and reduced their average monthly denials by 21 percent. Delays in claims submissions (or lag days), an important factor in revenue inflow, decreased 29 percent. 

The team helped Novant understand and work through the problem at a granular level to make sure the results were sustainable. “We needed to dig down to the root cause, and they’ve been instrumental in helping us get not just to root cause, but to resolution,” said Jones. “That’s what I’m excited about.”   

In the world of insurance denials, there’s always a new problem to solve. Black, Jones, and the Novant and Tegria teams are already working toward Novant’s next goal of expanding denials automation and enhancing claims statusing.  

“In my 25 years, I’ve never had a vendor come in to help my team that has every other team clamoring to work with them,” said Black. “But we have more for them to do.”