Becker's Hospital Review

35 Executive Briefing GE Healthcare provides transformational medical technologies and services to meet the demand for increased access, enhanced quality and more affordable healthcare around the world. GE works on things that matter – great people and technologies taking on tough challenges. From medical imaging, software & IT, patient mon- itoring and diagnostics to drug discovery, biopharmaceutical manufacturing technologies and performance improvement solutions, GE Healthcare helps medical professionals deliver great healthcare to their patients. enormous datasets to dig deeper into claim denials. Before hospitals had access to big datasets and analytics tools, hospi- tal staff lacked the ability to discern larger trends and patterns when reviewing claim denials. "It used to be like a paper-based inbox on your desk," said Travis Frosch, director of analytics and cybersecurity at GE Healthcare. However, with advanced analytics solutions hospitals and health systems no longer have to use this inefficient manual process. Leveraging analytics can help healthcare organizations im- prove performance by pinpointing the reason a payer denied a claim and uncovering denial trends. GE Healthcare's analytics solution, DenialsIQ ™, uses a statistical algorithm developed by GE's Global Research Center to uncover trends in claim denials. The tool performs root-cause analysis to uncover the issues that cause payers to reject claims. This insight helps hospitals and health systems appeal and reverse the initial denial and to fix the problem prospectively to prevent future denials. Analytics can also help identify claims that a payer improperly denied. The contracts between payers and providers dictate reimbursement rates, specify which services require prior au- thorizations and many other parameters regarding payment. It is vital for provider organizations to ensure incoming payments match the payer contract terms to avoid revenue loss. For ex- ample, GE Healthcare analyzed payments from one payer to a healthcare organization and found many improperly denied claims. "When we pulled their data through DenialsIQ, we were able to uncover about 1,200 denials that shouldn't have been denied under the payer contract," said Mr. Frosch from GE Healthcare. Since GE Healthcare launched DenialsIQ in 2016, the compa- ny has helped its customers uncover more than $2 billion in actionable health insurance claim denials. About 30 percent of those denials stemmed from coding issues and another rough- ly 20 percent were denied due to eligibility discrepancies. Timely filing, prior authorization and credentialing issues were also among the top culprits for claim denials. Gaining long-term sustainability with support To realize the full benefits of an analytics solution for denials management, hospitals, physicians and health systems need to know what data to prioritize or how to address the issues caus- ing insurers to deny their claims. Provider organizations also need to implement processes that will allow them to create a sustainable denials management program. After launching DenialsIQ in 2016, GE Healthcare recognized healthcare organizations needed more than an analytics solu- tion to drive the long-term change needed for an effective claim denials strategy. To address this issue, GE Healthcare partnered with Accenture, a global management consulting and professional services company, to offer provider organiza- tions GE Healthcare's analytics solution as well as advisory and consulting services. "We partnered with Accenture because we wanted someone with industry leading revenue cycle redesign experience…to leverage DenialsIQ and then take that next step with change management," said Mr. Frosch from GE Healthcare. A key determinant of a successful claim denials management strategy is sustainability. The GE Healthcare and Accenture partnership helps organizations achieve continuous improve- ment. After implementing GE Healthcare's advanced analytics solution, "Accenture comes in and deploys process teams to build out training, deliver training, standardize process and build out functioning claims denial strategy," said Mr. Gaydosh from Accenture. Once a hospital, physician or health system develops and de- ploys a plan to reduce claim denials, then it is time for individ- uals within the organization to take ownership of the strategy and accountability for improvement. Claim denials can occur at various points, including the front-end during registration and scheduling, while the service is being provided, or at the back-end of the revenue cycle. Many people are involved in the life cycle of an insurance claim, which means healthcare orga- nizations must establish clear lines of accountability to prevent blame shifting when a claim is denied or needs to be re-worked for appeal, according to Mr. Gaydosh. Conclusion Hospitals, physicians and health systems can reduce avoidable denials by deploying the right tools and processes to identify the precise root causes of denials, reverse the denial and put an improvement process in place to ensure the same type of denial does not reoccur. An effective claim denials management strategy requires stan- dardized processes and the deployment of advanced analytics in key areas of the revenue cycle to pinpoint the cause of the denials and then using that insight to prevent future claims from being rejected. Although technology is a key component, ev- eryone within a hospital or health system, from billing staff to clinicians, plays a role in driving this improvement. n "Before hospitals had access to big datasets and analytics tools, hospital staff lacked the ability to discern larger trends and patterns when reviewing claim denials."

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