The UM denials management nurse has helped the rev cycle recognize trends, gain better insight into the tactics payers use to deny claims, and successfully appeal claims.
In its work managing concurrent denials, the revenue cycle team at University of Wisconsin Health had a conundrum.
Although root cause data showed that 47% of its hospital billing denials were related to some case management opportunity, the staff that was tasked with working on utilization management (UM) denials didn't have much background in case management.
"It wasn't their expertise, so we were not being effective in appealing these denials," says Abby Abongwa, vice president of revenue cycle for University of Wisconsin Health.
That's why in 2019, they got a new position approved: A UM denial management registered nurse that reports to the revenue cycle department.
Abongwa presented her team's work on managing concurrent denials and described the creation of this new denial management nurse role during the HealthLeaders Revenue Cycle Ideas Exchange in mid-March.
"It made a huge difference for us since we got her onboard the revenue cycle team," Abongwa says.
The nurse that they hired has extensive clinical and case management and utilization management experience, as well as:
- Knowledge of the clinical decision support tools InterQual and Milliman Care Guidelines
- Experience with data management and reporting
- Knowledge of government regulations
This nurse acts as a liaison between utilization management and revenue cycle and works on concurrent denials; review and reporting; pre-claim review; appeals; process improvement; and data analysis and reporting. A revenue integrity nurse auditor and several clinical denials specialists (who are registered nurses) are also on the team.
Abongwa says their UM denials management nurse has helped the revenue cycle recognize trends and gain insight into the tactics payers use to deny claims. She also frequently reviews specific accounts and uncovers what might have been missed, such as a misapplication of criteria by InterQual.
"But most importantly, she has helped us be effective in appealing these denials and overturning a fair amount of them," Abongwa says.
That work has also helped to formalize and strengthen the relationship between the revenue cycle team and the UM team.
The ROI associated with this concurrent management work is impressive.
"We've been successful in capturing $6 million for fiscal year 2020 because of the work that she's been involved in with the other members of our team, and for year to date for FY '21 we're at about $5 million," Abongwa says.
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Alexandra Wilson Pecci is an editor for HealthLeaders.
