Episode Overview:

In this episode, we dive into the latest trends and challenges in the world of healthcare denials, focusing on payer-driven issues and solutions. The discussion spans denial trends, specifically around inpatient DRG downgrades, and the nuances of navigating denials and claim processes. We also cover technology gaps, regulatory shifts, and emerging solutions in the revenue cycle, particularly for claims with no response and payer-driven reimbursement barriers.

Key Topics Discussed:

• DRG Denials and Humana’s Query Compliance: Robin brings up a denial trend where Humana denies inpatient DRG claims based on “non-compliant queries,” prompting insights on how other professionals are tackling this issue.

• Technology for Claims Without Response: A compelling case is made for creating automation around claims that have not received a denial or payment. This includes potential decision trees for follow-up actions on claims without EDI data to improve efficiency.

• Prior Authorization and Payer Challenges: The conversation highlights the industry’s struggle with prior authorization, arguing that innovation should focus on reducing the overall burden rather than automating current processes, which only minimally alleviate providers’ challenges.

• The Telehealth Dilemma Post-2024: With telehealth flexibilities set to expire at the end of 2024, Whitney raises concerns over how practices primarily based on telehealth services, especially those offering behavioral health, will adapt. Regulatory changes are dissected, with possible strategies suggested to navigate this impending change.

• Innovations in Denial Management: Attendees discuss tools for denial tracking and payer insights, like Cleopatra Queen of Denial, a software solution developed to trend denial types across categories for better negotiation leverage.

• Building Technology That Truly Helps the Revenue Cycle: A call is made for technology that directly addresses payer-driven issues, rather than administrative burdens, suggesting a focus on innovation that simplifies payer policies and medical necessity criteria.

• Professional Events and Resources: The episode includes a discussion on upcoming events, like Joe Rivett’s denial forum, offering listeners insight into where they can learn more about denial management, payer perspectives, and effective appeals writing.

Listeners are encouraged to reach out and share their own experiences with denial management challenges, particularly around DRG downgrades and telehealth changes, fostering a community of shared insights and solutions.

Mastering Payer Defense

In this episode, Vanessa Moldovan, CEO and founder of 'For the Love of Revenue Cycle,' dives deep into the complexities of downcoding and mastering payer defense strategies. She discusses essential steps including understanding contracts, interacting effectively with payers, and leveraging legal options and state insurance commissions. Vanessa also shares insights gathered from a healthcare attorney specializing in defending providers against insurance companies. Tune in to learn actionable strategies to safeguard revenue and ensure fair payment while maintaining professional relationships with payers.

00:00 Introduction and Overview

00:13 Understanding Downcoding

00:53 Expert Insights and Strategies

02:20 Importance of Contracts in Payer Defense

03:49 Presenter's Background and Expertise

06:00 Webinar Disclaimer and Initial Questions

07:10 Best Practices for Denial Escalation

11:39 Identifying and Addressing Downcoding

19:58 Effective Payer Conversations

29:22 Navigating Payer Relations and Contracting

31:01 Effective Appeal Strategies

33:40 Documentation and Professionalism

37:43 Leveraging State Insurance Commissions

43:33 Filing Grievances: Medicare and Commercial Plans

48:47 Legal Complaints and Final Steps

52:19 Q&A and Closing Remarks

Transforming Healthcare Revenue Cycle with Technology and Human Expertise

Join Vanessa Moldovan, CEO and founder of For the Love of Revenue Cycle as she delves into the intersection of innovative technology and Revenue Cycle Management (RCM). Discover the critical role of technology such as Artificial Intelligence (AI), Large Language Models (LLMs), and Software as a Service (SaaS) in optimizing financial processes and patient data management.

This episode covers essential topics including vendor selection, key technological terms, and the importance of human factors in successful technology adoption. She tackles common objections to new technology, and provides practical strategies for evaluating software solutions and maximizing the benefits of software demos.

Learn how to balance human intervention and automation to achieve efficiency and long-term financial success. For more information, contact Vanessa at vanessa@ftlorc.com and connect via LinkedIn or Facebook.

00:00 Introduction and Webinar Overview

00:11 About Vanessa Moldovan

00:48 Mission and Services

01:58 Importance of Technology in Revenue Cycle

05:50 Key Terms in Technology

09:37 Understanding Information Technology

11:31 Software as a Service (SaaS)

28:50 Human Factor in Technology

35:49 Challenges in Revenue Cycle Management

36:57 Understanding Common Objections to Technology Adoption

37:55 Overcoming Resistance and Bad Experiences

40:07 Perception of High Costs and Value Challenges

42:34 Preparing for Technology Demos

44:46 Maximizing Demo Effectiveness

50:39 Evaluating Technology Integration and Support

01:03:36 Exploring Innovative Technologies in Revenue Cycle

01:10:29 Conclusion and Contact Information