Defeating the Denial Engine
How a New Breed of Software is Bleeding Providers Dry, and How to Build, Buy or Demand Tools and Techniques to Put a Stop to It
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How a New Breed of Software is Bleeding Providers Dry,
and How to Build, Buy or Demand Tools and Techniques
to Put a Stop to It
Online Seminar. CEU: 1.5 clock hours.
The February sessions have concluded.
Click here to be notified of upcoming events as dates are scheduled.
Order the Video DVD
Correct Coding Initiative Edits. Duplication of Services Edits. Bundling and Unbundling Edits. Pretty familiar territory in the world of healthcare claims, right? They’ve got their edits; we’ve got our edits. Right?
Think again.
There is a new category of software tools that payers are bringing to bear on the adjudication process that is an order of magnitude more sophisticated than providers have faced in the past. So sophisticated that some of the vendors don’t even charge a license fee – they just collect a contingency on the millions of dollars that get stripped out of providers’ monthly checks. So deep and so broad is the technology that it allows the payer to set a tolerance level – what percent of outbound payments do you wish to retain? How much will your providers put up with?
It’s time to put a stop to it. We’ll show you how in this 90-minute presentation.
A Denial Engine runs in addition to and before the regular adjudication process – even before the payers’ own automated claims filtering systems. It can also be applied to claims history – capturing “overpayments” and deducting dollars from current remittances. And the engine has a throttle – throttle up the engine to engage more obscure edits to boost payer profits; throttle it down if providers get too peeved. Payers can now simply decide how much they want to pay out. Quarterly profits sagging? Deny more claims.
Is it legal? Is it ethical? Surprisingly, yes. Or at least they can be used within a legal and ethical framework. Denial Engines typically deliver automated defense documents that reference providers’ own practice standards and published sources, in addition to payer contract terms and payment policies. The unprepared provider may simply take these at face value, and decline to appeal. That’s the response these tools are designed to evoke.
For nearly two years, Healthcare IT Transition Group has been researching the Denial Engine and closely tracking its evolution. Our research has captured the emerging picture of this new technology, and provided a framework for tools and strategies providers can use to implement against them. (IMPORTANT NOTE: This is not a sales presentation. We neither recommend nor promote particular vendors, products or services. Examples are provided, but it is not the purpose of this presentation to evaluate particular software offerings or services.)
The presentation reveals the systems and the economics involved, lays out a methodology for providers and software vendors, and provides a schematic overview of the Approval Driver, an application designed to pierce payer armor and get claims through to adjudication. The nonexclusive right to adopt or expand upon this design is included with your payment.
 Audience
- Practice management software (PMS) developers
- Provider software vendors
- Revenue Cycle Management (RCM) specialists
- Provider Business Office Staff and IT Support
- Billing Service managers and executives
- Clearinghouse Provider Support Staff
Topics Covered
- How Denial Engines differ from traditional claims editing approaches
- Why payers are rushing to implement these tools
- FRAUD! (and abuse) vs. (fraud and) ABUSE
- Where Denial Engines enter the claims process
- Pre-adjudication front-end edits
- Integrated/enhanced adjudication
- Post hoc reviews/Recovery Audit Contractors
- Clearinghouse “value added” services
- Who are the players?
- Denial Engine Vendors
- Published alliances and CH relationships
- How can you tell if a payer is using a DE?
- Getting Claims Paid Despite DE
- Upstream documentation and coding maximization (including CPOE)
- Contract management systems
- Automated appeals
- Serve-and-volley challenges
- Why your vendor isn’t protecting you
- “Approval Driver” – an exclusive HITTG design schematic you can use to develop an anti-Denial Engine system
Q & A session will follow the presentation.
Course Materials and Bonuses
- Handouts in printable form
- Slides with live resource links
- Denial Engine Vendor Resource Sheet with links
- Denial Engine Clients and Partners – who is using this technology?
- Recover Audit Contractors Intelligence Report
- Approval Driver – an exclusive HITTG design schematic
Meet the Presenter
 "One of the few people in the industry who can truly be called a leader in thought."
~Michael Apfel, Truman Medical Centers
Martin Jensen is Chief Analyst and a principal partner at Healthcare IT Transition Group, a consultancy whose clients include healthcare providers large and small, health IT software and service companies, and some of the nation's largest health plans. Currently, Marty is involved in NPI remediation projects in state Medicaid, vendor and payer organizations. His seventeen years in healthcare IT include recent work in health plan NPI remediation and provider outreach, engagements with software vendors in NPI-related product development and systems design, and over fourteen years in business analysis and project management for provider organizations. In 2004, he presented the findings of a national survey on Provider Taxonomy to MMIS officials. Marty was recently honored with the Workgroup for Electronic Data Interchange (WEDI) Distinguished Service Award for his leadership.
Marty was involved in the first-ever WEDI/X12 Real-Time Claims Adjudication Forum in February, 2007, and co-chaired the newly-developed health ID card standard.
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Keywords: claims, claims denial, adjudication, RAC, 835, 837, 835, rta, rtca, real-time claim, real-time adjudication, health information technology, health IT, healthcare information technology, healthcare IT, 837 PRV, CMS, crosswalk, CR4023, CR4320, HIPAA, MM4023, MM4254, MM432,0 MM5229, MM5243, R1024CP, R1054CP, R815CP, R983CP, EDI 837, Medicare, Medicaid, health plan, health insurance, provider crosswalk, enumeration, online seminar, webinar, training. |
