Recently I was asked to discuss what skills make denials representatives more effective. A few important things came to mind.
To ensure that a representative is able to efficiently work denials and appeals, they should prioritize their worklists first by payer, then by patient type (IP or OP), and then by underpayment descending. This structure allows the rep to focus on the same contract rates and payment methodologies for an entire batch of accounts so she is not relearning a new contract each time she moves to another account. Additionally, prioritizing by underpayment amount helps her focus her efforts on those claims that are the most lucrative for the facility, and are likely to be worth her efforts.
Knowledge of contract terminology and stipulations
To capitalize on the smart workflow, the rep should also have deep knowledge of how managed care contracts work, be able to easily navigate allowable calculations using the contractual rate sheets and codes billed, and be cognizant of all timely filing deadlines and mandates for additional documentation.
Sometimes a successful follow-up call simply comes down to how confident the denials rep is on the phone. If she can assertively state how a claim was paid, how it should be paid, the amount that is still due, and what the next step in the path to resolution should be (like sending the claim back for expedited review), the insurance representative may be more likely to comply. In my own experience conducting follow-up calls, my claims reached resolution faster when I was able to escalate my claims and explain the issues clearly, calmly, and with authority.
What does your organization do to give denials representatives the tools they need to be successful? To learn about how HBI is helping organizations with this, fill out the form below!