Quick Facts About Health Insurance Exchanges (HIX)

America’s current status of HIX: The deadline for states to declare their intentions on whether they will build their own exchange or have the government do it has been extended to Dec 14. Some states are currently undecided, but policy leaders are warming up to HIX overall now that the election is over and there appears to…

Election Results: What Do They Mean for Healthcare?

Now that the election season has come to a close, what does that mean for us in healthcare? Will Legislation Change? HITECH Act – No change, unless budgets are overturned; includes Meaningful Use, HIPAA Security, and Health Information Exchanges (HIE). The funding for these programs is relatively secure with either party having a majority. Adopting…

Create Interoperability Now for Changes Ahead

As the use of various technology systems continues to increase within medical practices, interoperability between those systems becomes critical. An article called, “Interoperability a Key to Effective Communication” on the AAPC website states, “Disparate computer systems must communicate structured data in a way that both systems understand.” Consequences of having disparate systems could mean a…

Importance of E/M Outliers for Current Clients

In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar with their…

Importance of E/M Outliers

In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar…

CLDPP to Combat Increasing Payor Rules

AMA’s 2012 National Health Insurer Report Card provides interesting insight into what the revenue cycle might look like in the next few years (Learn more about the AMA 2012 Report Card, here). There are two interesting observations on the data that need to be considered with respect to what types of tools provider organizations will need in the future…

AMA’s 2012 National Health Insurer Report Card

The AMA has published its National Health Insurer Report Card, comparing data from seven commercial payors and Medicare on key administrative metrics. While there have been great improvements that have saved the healthcare industry billions of dollars, this report shows a few interesting findings that directly correspond with a physician’s bottom line. Click HERE to continue reading. 

Finalized ICD-10 Implementation Date and Stage 2 Meaningful Use Requirements

Today, CMS made final a one-year proposed delay (from Oct. 1, 2013, to Oct. 1, 2014) in the revised ICD-10 implementation date.  The CMS final rule report ends months of speculation about the timing of ICD-10. Practices and providers will need to make preparations well in advance of the conversion date to prevent revenue losses.

In addition, an extended timeline for early adopters of Meaningful Use has been adopted. The Stage 2 rule gives providers more time to meet Stage 2 criteria. A provider that attested to Stage 1 of meaningful use in 2011 would attest to Stage 2 in 2014, instead of in 2013. Therefore, providers are not required to meet Stage 2 meaningful use before 2014. For more information, please click here.  

Creating a Closed Loop Denial Prevention Process

So, how do you create a Closed Loop Denial Prevention Process?  It requires a rules engine capable of finding claims that are destined for denial; preferably before they are posted to the PM system so that backend modifications and corrections are not needed and without creating a lag time prior to submission with negative cash flow impact.

With AccelaSMART, White Plume clients use their denials experience and payor communications to proactively set up customized rules. These rules are designed to prevent denials and improve 1st Pass Pay rates (the rate at which claims are paid with the first submission).  The customization available within AccelaSMART allows users to set up the specific criterion that applies to their services, coding, master files, providers, region, plans and other details about a specific claim to ensure it will pass the payor’s edits.  Think you don’t need that much granularity?  Remember, United Healthcare applies over 82,000 rules to adjudicate claims over and above the industry standards.  Think about that. 

Diagram 1 depicts a Closed Loop Denial Prevention Process, starting with the advent of a new policy or denied claim, building a customized rule to catch conditions that will trigger a denial, enabling the rule for all billers to use and thereby preventing the denial from happening again.

Diagram 1. – Closed Loop Denial Prevention Process

The great thing about a Closed Loop Denial Prevention Process is that it is scalable and uniform across an organization.  The process can be applied consistently for each biller, regardless of their experience, skill sets and day-to-day distractions.  It improves productivity with workflow designed to minimize errors and streamline corrections.  Using a closed loop process significantly reduces the time clinicians spend on getting claims paid and puts process improvement at the right point in the life cycle of a charge. 

Ultimately, a Closed Loop Denial Prevention Process improves cash flows and profitability by ensuring claims can be paid as they should be, quickly and completely.

Preventing Reimbursement Denials in Context

To better understand what a closed loop denial prevention process is, let’s first examine what the opposite would be and study what normally happens when a payor implements a proprietary rule.  According to AMA’s 2012 National Health Insurer Report Card, Aetna has over 62,000 proprietary rules in addition to over 1 million edits that are considered “industry standard”.  Table 1 shows the total number of claim edits by rule source, by payor.

Table 1. – Total number claim edits by type and payor
























































In an environment where payors have free reign to define their rules and disclosure is optional; providers have to keep up with the ones that apply to their specialty, location, services, patient panel and other criteria.  Sometimes, advanced notification of the rules’ implementation is communicated in a newsletter, typically weeks before enactment.  Billers rely on manual methods (sticky notes) and to a large extent – their memories – to comply with these rules and count on their clearinghouse to catch what they have missed. 

But clearinghouses don’t always supply the means to catch all the proprietary rules and don’t delve into the granular nuances that aren’t applied nationally.  Catching these types of corrections is normally left to the intellectual capital found in a key employee or two who just “know” how to get claims paid; based on previous denial experience and their diligence in keeping current with new rules.  They are a valuable commodity and subject to the frailties of mankind, if not the lure of a better position or a different career path.  This describes the open loop process of denials prevention – relying on staff to remember and catch a soon to be denial before it is submitted.

Now how do you create a closed loop denial prevention process? Stay tuned for the next post!