Business Solutions: Conifer's Mike McMann Talks Best Practices for Denial Prevention

This episode of the MGMA podcast features Mike McMann, Vice President of Client Management Physician Services at Conifer Health Solutions.

Conifer offers end-to-end revenue cycle solutions for health systems, hospitals and medical groups. They also offer a value-based care division that provides population health management services.

MGMA Sr. Editor Daniel Williams, MBA, MSEM and McMann discuss Conifer’s multi-faceted healthcare solutions and McMann’s healthcare journey while exploring best practices for optimizing denial prevention.

Editor’s note: The following Q&A has been edited for length and clarity. 

Q. Tell us a little bit about what Conifer Health Solutions does.

A. Conifer Health offers end-to-end revenue cycle solutions for health systems, hospitals and medical groups. We also have a value-based care division that offers population health management services. Whether you're in a hospital-specific setting, a physician-based operation, or value-based care, we can offer end-to end-solutions starting with patient access, eligibility and enrollment, and things of that nature – so basically A-Z in terms of the revenue cycle operations, but we can also offer point solutions. Particularly during COVID, when clients were struggling more with just maybe finding certified coders to help with their coding, they might come to us and say, “Can you just help us with coding in our emergency department or our radiology department?” So we've done a lot of that in recent years largely driven by some of the challenges created by COVID. If you just want assistance with eligibility and enrollment or authorizations, we can do that for you as well. We obviously like to offer the full suite of services. We have eyes and hands on everything so we can be most efficient and perform at our highest level.

Q. What do you see as your primary role there and what are you focused on?

A. I am the VP of client management, so my team is the interface team between our client organizations and our organization. We're out in the field working with clients to make sure that we're delivering on the promise in terms of our key performance metrics, specifically as they relate to service level agreements that are within our agreements with our clients. But then also at the same time, we work closely with the operators [in house] to make sure that what they're focused on is in alignment with what our clients are wanting in terms of financial outcomes. We also get valuable information from our operations teams so that we can share that information with our clients, particularly if they have more responsibility for the front end of the revenue cycle, which is often the case with a lot of our clients.

We're really out there being an advocate for our clients demonstrating on a regular basis, “here's where you're at from a performance standpoint, there's your charges, your payer mix, your gross collection and things of that nature.” We focus a lot on denials and denial management. If there's a spike in a certain type of denial, the client delivery team is kind of your first-pass analyst. And so you should start digging into some additional reports that help you to identify where the source of that issue may be. You're going to also want to circle back to the operations team and get their feedback if they're seeing the same thing as it relates to maybe that new denial trend. So again, client delivery is kind of the one team that is talking to everybody with a lot of touch points at the client, and then a lot of touch points internally at Conifer to make sure we’re all humming as one fine-tuned machine.

Q. Tell us a little bit about your healthcare journey and how you got to where you are today.

A. I started as a nurse in healthcare over 30 years ago. At the University of Chicago hospitals, I learned a lot as a nurse. I was one of those nurses who never shied away from administrative initiatives where they wanted to improve patient satisfaction or supply-chain initiatives. Most nurses ran in the other direction, so I usually stepped forward over time. I got recruited into administrative roles and then kind of burnished my credentials to go along with that from a business administration standpoint. So I moved into administrative roles where I largely managed physician based operations – a lot of what our clients are doing today. I was very much focused on clinical operations and delivering the highest level of care that we could for our patients – making sure that the clinical or diagnostic and treatment area that I was responsible for was working very well, starting from when patients start lining up at the door. I always [maintained] responsibility for the revenue cycle all the while as well, but more so towards the front end like a lot of our clients are today.

Then I came into this role about 10 years ago. Those prior roles really kind of helped me fill my toolbox with all the tools you would need to do what I'm doing now: talking to our clients, helping them understand the challenges of the revenue cycle and dealing with the payers which is kind of the heaviest lifting we do. It helps that I lived all of that both from a clinician standpoint and then the administrator standpoint. Now that my job is to be talking to the clients all the time, I can really speak very directly to what it is they experience because I lived through it for so long myself.

Q. From a general standpoint, what is it about denial prevention that caught your attention and led it to be what your practice focuses on?

A.  One of the primary goals that we always repeat constantly to our clients, to our co-workers and to anybody who will listen is that maximizing your initial clean claim rate or minimizing your initial denial rate is key, for no other reason, than it's expensive to work it out. It adds a minimum of 30-60 days to the revenue cycle in terms of getting your reimbursement. So you may not have reimbursement denied, but you're certainly going to have reimbursement delayed. And then even when you do realize that reimbursement, you've now got a fair percentage of that reimbursement going to pay for the work that it took to work the denial. So we really strive to have clients that have a 95-97% or higher clean claim rate, because that's what's best for everybody involved including the patient. But the reality is that denials are a reality, and you want to do everything you can to help minimize those things. A lot of that stuff does happen on the front end. So we're very regularly working with our clients on relying on the tools that we have available to either us in our billing platform, or the billing platform of the clients that we often use to say, “let's take advantage of the tools in your EHR in your system to stop that claim before it goes out incorrectly.”

Q. What is happening in practices that is causing gaps in denial prevention?

A. It’s really just focusing on the details of all the processes that you have on the front end. A lot of denials will happen related to front end processes. People are focused a lot on more of the “let's just get the patient in and registered and get the care delivered.” And so along the way, you have to have a really good process for patient access and eligibility and making sure that people that are responsible for that don't have distractions. There’s a lot of good eligibility tools out there, but if your staff aren't well trained – and don't know what to do with the information that comes back – when you run an eligibility check, then you're going to potentially have some issues.

It’s as simple sometimes as making sure you pick the right Blue Cross Blue Shield plan. You run Mike McMann through and it looks like he has BlueCross BlueShield, but you pick the wrong plan and now you're going to get a denial for coverage reasons. So having really tight front end processes that are highly focused on data integrity sounds like simple stuff, right? Now the provider needs to be as thoughtful about their documentation and the data integrity associated with that. If you are going to have a need for an authorization, do you understand what this payer requires? Because that's going to require a certain level of data. Some payers’ tools are better than others, but all along the way, it's having defined processes, people understanding their roles and always focusing on a very high level of data integrity.

Q. What are some steps that practices can take to begin to turn these trends around?

A. Going back to eligibility, as much as you can, kind of separate some of those functions so you don't have distractions. You want to make sure you're checking it like four days in advance of a visit. Then when the patient's right across from the person checking in for their visit, you don't have a very limited opportunity at that point to try and confirm the patient's insurance information. So make sure that you're capturing it correctly at the point of scheduling and registration, and that you're using the eligibility tools in advance of the patient arriving for the visit. [It’s about] understanding those processes so that it’s all done very well, and if you do it really well – depending again on the capabilities of the tools that you're using – you should be able to tell Mike McMann that he's got a $20 copay and then that makes that easier to collect at the front desk. Staff sometimes have a hard time asking for copays, but if you know it's accurate, and the patient knows it is as well, everybody's generally happier. But you have to really use the tools. Even when the patient does arrive, if you don't have a scanned image of their insurance card available, make sure you capture that at that point so that you may even capture that there's an inaccuracy there. Focusing on all those details with the eligibility information upfront is really key.

The same principles apply even as you move into authorizations. It requires a lot of patient information, but now you have to leave their diagnosis code [or] the CPT codes that are tied to the procedure that you're looking to get authorized. Sometimes you may need to submit medical records from the physician. And again, sometimes that's as easy as scanning and uploading something; sometimes it's not as easy. Some payers don't want it right away, so you need to be aware of that. Also make sure that the provider is involved in that process as well and they're giving you really good information. Even when they are and you get a procedure authorized, make sure then that during the delivery we have care when the provider changes the procedure that's been approved, which happens pretty frequently.

All of that is understanding the process, understanding people's roles, and getting right back to data integrity because it's only as good as the quality of the data that you're putting in –whether it's the diagnosis code, CPT code or the medical records.

Q. Once you have those steps and best practices in place, what are some KPIs (Key Performance Indicators) you'd recommend practice leaders study and follow?

A. Initial denial rate is huge and initial clean claim rate is the flipside of that, but there’s also final denial rate as well. If you're doing well with your overall revenue cycle operation, your final analysis should never really be over 2%. We strive to have our clients between 1-2% with most of them hanging around 1.4-1.5%. That's pretty good. You can get under 1% final denial rate, but that's going to depend on the specialty a little bit. Primary care tends to be a little easier and cleaner.

But if your initial denial rate is above 7-8%, final denial rate is about 2-3%. That's one of your early indicators that you’ve got some opportunities. So beyond that, it's your days in AR (Accounts Receivable). How long does it take you on average to get paid for a clean claim? You want to be in the 30-35 day range. You can sometimes be below that. We're fortunate at Conifer. We actually have some pretty large, complex, multi-specialty academic clients where we are below 30 days in AR. So we're averaging less than a month on all claims combined in getting those things paid timely and cleanly.

Another good aging metric is AR greater than 90 days – that’s how much accounts receivable is older than 90 days and hasn't gotten any payment or any type of resolution whatsoever. We like to stay 90/90, meaning 90% of your AR is under 90 days. We don't always quite get there, but that should always be the goal. And then there’s also AR greater than 365. You shouldn't be hanging onto more than 2-3.5% at most of your AR that's aged over a year. If you have AR that's aged over a year and it's 10% of your total AR, you’ve probably got a lot of no-value AR hanging out there that you probably need to clean up and adjust. Take a look at how it got there to begin with and try to avoid that because that number should never climb into the double digits.

We also look at nine-month denial resolution rate. That's a good one that kind of gives a good indicator of what our third-party follow up denial management team is doing. We try to make sure that any and all denials (85-90% or more) are fully resolved at the nine-month mark. So whether that's paid or adjusted off, whatever the case may be, it's not hanging out there still being worked. We always said 85% is our internal goal. I can tell you that all of our clients are well above 85%.

And then specific to coding, you want a good turnaround time. From the time the provider completes the documentation – they close the encounter and it lands in a work queue for a coder to work – that should usually be two to three days. You don't want that to be held up any longer than it needs to be. Then there’s coding accuracy. We here at Conifer have a pretty strict quality program where all of our coders need to be at 95.5% accuracy or greater. Not everybody hits it every single month, but for the most part they do. If we ever see more than one month where you're off the mark, that coder is going to get some education and training – and we'll continue with that if we need to.

Q. Do you have a success story you could share with us about a practice that's utilized some of these tools and seen things change for the better?

A. We have a safety net hospital down in the southeastern United States. Starting with their emergency room and in all of their service lines, they had a lot of variability in terms of their coding quality – a lot of it tied to provider or clinician documentation. We knew just from doing a little bit of hunting and pecking in analysis that there was certainly opportunity there – for no other reason than all of the writers in the emergency room had very different outcomes in terms of what they were documenting and what they were coding. So we started there, but we expanded it through the rest of the other specialties and service lines.

We started with a full-blown clinical documentation improvement program, which is led by a physician here at Conifer and a host of other auditors. We took 10-20 charts from every single provider and did a very full thorough audit of all their charts. Sure enough, we come to find out there were oftentimes things that were being done and weren't documented, or things that were being misunderstood to be potentially more complex than what they really were right. So there were opportunities for adjusting codes up and adjusting codes down, but mostly there was opportunity for improving the clinicians’ documentation. As an outcome of all those audits, we had individual one-on-one physician education that was extremely well received. We routinely got feedback from the physician saying, “I never knew I was doing this wrong for the last 5-10 years. Thank you so much for this feedback.” And sure enough, clinical documentation accuracy improved, coding accuracy improved, and reimbursement improved for virtually all the providers in the ED (Emergency Department) – over 20 physicians.

Then we moved from service line to service line and we found the same type of experience and outcome with all the other service lines, particularly the more complicated they were. So for the surgical subspecialties that we engaged, we usually found more opportunity for the providers and to document what they were doing.

Having said that, each one of those departments experienced an improvement in all those facets and areas. Each one of them improved their reimbursement and their financial outcomes at the end of the day. They were all extremely excited and I have to believe that that success story is one of the reasons why that client renewed with us for another three years.

Resources

• Conifer
• Mike McMann
• Denial Prevention