Throughout the pandemic, many hospitals had to delay elective procedures for several months or cancel them altogether. Surgical volumes decreased over 35% in 2020 from March to July. This has led to a projected backlog of elective procedures and surgeries. For example, in orthopedic surgeries such as joint replacement and back fusion, it was estimated the pandemic would generate a backlog of over one million surgical cases. If you multiply that across all the surgical specialties and then add on the other elective testing procedures such as imaging or outpatient testing, there is a cumulative effect of delayed healthcare for patients and a high backlog of case volume for healthcare providers. Physicians, healthcare facilities, and providers are currently working their way through this backlog of delayed care as the pandemic is shaped by the roll-out of COVID-19 vaccines and updated COVID-19 guidelines.
As providers and hospitals work through the newly scheduled elective surgeries and care related to the backlog, there’s also a corresponding increase in the number of claims filed. Both providers and payers experience this increase in volume. Most of the changes related to the pandemic have been in three areas: new COVID-19 codes, expanded telehealth rules, and federal guidelines for coverage of COVID-19 testing by insurance. As these claims for the backlog are not for billing changes related to the pandemic and are related to traditional medical services, the payer’s prior authorization, clinical review requirements, and billing guidelines to substantiate the services remain largely unaffected by COVID-19. This means for providers is a large increase in the volume of claims where the traditional requirements to substantiate services such as prior authorization, medical records submission, or clinical review on submitted medical records. This also means a related increase in the volume of claims payers review for medical review on these elective procedures.
For providers and hospitals, re-scheduled elective surgeries and claims submission requires planning for additional volume within the revenue cycle and denials management. As these claims are for elective surgeries, imaging, and outpatient services, there is a corresponding increase in clinical denials for these services with the increased claim volume from the backlog. Provider RCM services and hospital clinical denials team resources are further stretched with the same pre-pandemic requirement for submitting prior authorization requests, medical record documentation, post-claim medical record requests,s and appealing the increased number of denials. Providers and hospitals are looking for creative ways to meet the old saying, “Dd more with less.”
The traditional route of handling claims denied for clinical reasons such as “prior authorization missing,” “not medically necessary,” “experimental or investigational,” “level of care”, or other reason is even more crucial to re-examine in the wake of the pandemic effects on the healthcare system and the creation of backlog from delayed elective surgeries/procedures. The traditional method of working with nurses or other healthcare professionals for clinical denials management with manual clinical denial record review, traversing multiple systems, extensive case review, and working with multiple parties on the denials become more ineffective with increased volume. Providers and facilities must re-look at how they can complete PA requirements, appeal more claims, and appeal effectively on denial root cause with higher volume and constrained resources.
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Prior to the pandemic, HFMA reported that “65% of denied claims are never resubmitted.” As this is the current rate of not re-working/appealing denials prior to COVID-19, volume from the pandemic backlog will likely increase the rate of unworked clinical denials when approaching appealing clinical denials with a traditional method. Once you add in the component of requiring to solve for denials from multiple payers with varied clinical policies, providers and hospitals are constrained further. This brings the perfect time to “update” the clinical denial landscape and the environment with a fresh look at the opportunities that technology can bring to the process. Technology can assist providers and hospitals in handling post-pandemic elective surgery/procedure denied claim volume, increasing their appeal rate and efficacy, and increasing revenue through several claims appealed and overturned. This approach also allows providers and hospitals to focus key clinician time on the clinical denials requiring their attention the most, and pinpoint their review process to allow for effective clinician allocation.
The goal is to:
– Focus re-work effort where the clinical denials that have a higher propensity to overturn
– Key in on the medical record documentation required to review in order to support the services for a prior authorization request or an appeal submission
– Effectively target appeals to the root cause of the denial as related to the individual payer clinical policy to enable the highest possibility of denial to overturn
– Quickly create targeted medical record output that supports the appeal submission
– Automate appeal templates and workflows to enable faster denial processing and appeal submission
Source: Hitconsultant
