September 10–11, 2024
DENIALS MANAGEMENT
The Denials Management Exchange is proudly sponsored by:
DENIALS MANAGEMENT
The Association of Clinical Documentation Integrity Specialists (ACDIS) is the nation’s only association dedicated to the CDI profession. ACDIS’ mission is to serve as the premier healthcare community for clinical documentation specialists. Since its inception in 2007, ACDIS has grown to nearly 7,000 members nationwide. ACDIS members enjoy the benefits of a membership journal, access to their peers in a CDI forum, helpful forms and tools, a CDI job board, and much more—including quarterly membership calls and the biweekly ACDIS Podcast. They also receive discounts to the association’s boot camp offerings and its national conference. ACDIS provides guidance and advocacy on behalf of its members and the CDI profession through its staff leadership, elected advisory board, local chapter leadership, and other boards and committees.
HEALTH & SAFETY: HCPro LLC places the highest priority on the safety of our guests. To safeguard all those in attendance at our events, we ask that you stay home if you are feeling unwell. If at any time you need support, please feel free to contact our event staff.
The National Association of Healthcare Revenue Integrity (NAHRI) is the nation’s only association dedicated to the revenue integrity profession. NAHRI’s mission is to enhance the revenue integrity profession through standards, advocacy, networking, and the promotion of shared knowledge and resources. NAHRI members enjoy the benefits of a membership journal, access to their peers in a revenue integrity forum, helpful forms and tools, quarterly membership calls, and much more. NAHRI provides guidance and advocacy on behalf of its members and the revenue integrity profession through its staff leadership, advisory board, and other boards and committees.
By accepting the invitation to the Denials Management Exchange, ACDIS/NAHRI will provide you information about the program, or about the content for which you registered. ACDIS/ NAHRI may also share information about other ACDIS/NAHRI conferences, products, and services, as well as messages from our strategic partners about their products and services. In addition, for events, programs, or content presented in collaboration with certain strategic partners, ACDIS/NAHRI will share registrant contact information with the applicable strategic partner. Information you provide will be processed in accordance with the ACDIS/ NAHRI Privacy Notice. You may opt out at any time by contacting the ACDIS/NAHRI staff who invited you to participate in the Exchange.
WELCOME
Welcome to the inaugural ACDIS/NAHRI Denials Management Exchange!
We know that hospitals are under more and more pressure from denials, impacting their bottom lines and the resources they have available to care for patients. Those in the revenue integrity and clinical documentation integrity (CDI) fields are increasingly being asked to help fight the rising denial tide. And it’s no small task.
In this first joint effort between the Association of Clinical Documentation Integrity Specialists (ACDIS) and the National Association of Healthcare Revenue Integrity (NAHRI), we aim to bring the best and brightest leadership minds in the revenue integrity and CDI worlds together to discuss how their organizations are tackling the problem of denials. Over the next couple of days, leaders will have the chance to share their prevention techniques, unpack their approaches to the many types of denials, and discuss what metrics they choose to track, trend, and leverage in the denials management space.
The Denials Management Exchange helps give leaders the tools they need to advance their denials management program, chart their own leadership journey, and lead their staff members effectively. Plus, it connects them with other leaders experiencing similar challenges—an invaluable resource. Our goal over the next two days is to share ideas with each other and give you an enjoyable opportunity to recharge.
A very special thank you to our sponsors, CorroHealth and Solventum, whose financial support makes our Exchange possible. We believe you will find this time to be a valuable exchange of ideas with the companies that deliver essential tools and intelligence for the industry.
We are looking forward to hearing your thoughts and insight as part of the event discussions, but we also hope you are able to participate in the extracurricular events and enjoy your stay at the Hilton Chicago/Oak Brook Hills Resort & Conference Center.
Rebecca Hendren Director of CDI and Revenue Integrity HCPro
PROGRAM AGENDA
TUESDAY, SEPTEMBER 10, 2024
5:00–5:30 p.m Registration & Cocktails – Mallard Room
5:30–6:30 p.m. Event Welcome & Lightning Round Presentations – Mallard Room
6:30–8:00 p.m. Networking Reception – Medinah Room and Patio
WEDNESDAY, SEPTEMBER 11, 2024
8:00 a.m Buffet Breakfast – Conference Dining Room
8:30–8:45 a.m. Event Kickoff – Conference Dining Room
8:45–10:00 a.m. Round A Sessions
Editorial Session #1: Denial Prevention – Augusta Meeting Room
Editorial Session #2: Tactics for Different Denial Types – Pebble Beach Meeting Room
Editorial Session #3: Reporting and Tracking Denials – Doral Meeting Room
10:00–10:15 a.m. Break – Foyer
10:15–11:45 a.m. Round B Sessions
Sponsor Session – Solventum – Augusta Meeting Room
Sponsor Session – CorroHealth – Pebble Beach Meeting Room
ACDIS/NAHRI Editorial Session – Doral Meeting Room
11:45 a.m.–12:45 p.m. Networking Lunch – Conference Dining Room
1:00–2:15 p.m. Round C Sessions
Editorial Session #1: Denial Prevention – Augusta Meeting Room
Editorial Session #2: Tactics for Different Denial Types – Pebble Beach Meeting Room
Editorial Session #3: Reporting and Tracking Denials – Doral Meeting Room
2:15–2:30 p.m. Break – Foyer
2:30–4:45 p.m. Round D Sessions
Editorial Session #1: Denial Prevention – Augusta Meeting Room
Editorial Session #2: Tactics for Different Denial Types – Pebble Beach Meeting Room
Editorial Session #3: Reporting and Tracking Denials – Doral Meeting Room
6:00–8:00 p.m. Closing Reception & Dinner – Sugar Maple Room
8:00 p.m. Adjourn
DISCUSSION GUIDE #1
Denial
Prevention
Session Moderator:
Karla Kozak, ACDIS Editorial Manager for Products and Events
Synopsis
Denial volumes for most organizations have been steadily increasing over the years. As a result, revenue integrity and CDI leaders are often tasked with developing processes and solutions to stem the rising tide. However, that is easier said than done. Leaders must determine who needs to be involved in prevention activities, who will own the processes ultimately, and what responsibility each department and individual holds. Then, once processes are in place, leaders must constantly evaluate how their efforts are paying off and make adjustments in real time to continue to meet denial demands.
During this session, participants will discuss how they prevent denials on the front end, work proactively across departments, assign ownership for denial prevention activities, and follow up on prevention processes for continued improvement.
Key questions to consider during this session:
• Does your organization have a proactive denial prevention program? Does your organization conduct denial prevention activities, but not under the aegis of a recognized program? Or is your organization’s denial prevention process a more reactive approach?
• What departments are involved in denial prevention activities at your organization? Do clinical staff play a role, and if so, how?
• Who on your team is involved with the denial prevention process? Does a specific person (or group) always handle denial prevention issues, or is the work spread out in some way?
• What role do queries play in denial prevention? Do you have query goals or target diagnoses that align with denial prevention targets?
• Who owns the denial prevention process? Does one department take point, or do multiple departments share responsibility?
• What activities take denial prevention into consideration? Are you conducting root cause analysis of denials?
• Do you share denial data with providers and leadership to refocus prevention efforts, or do you keep that information within frontline denial prevention staff?
• How is responsibility assigned for following up on the results of denial prevention activities? Who oversees sharing of results, implementation of solutions, and education?
Tactics for Different Denial Types
Session Moderator:
Linnea Archibald, ACDIS Associate Editorial Director, Publications & Membership
Synopsis
Payers deny cases for a myriad of reasons, and those on the receiving end must adapt their appeal strategy accordingly. Each type of denial requires those fighting it to provide different evidence to support their appeal. This may require them to collaborate with many departments or individuals to build the case. All these nuances can leave a leader feeling at a loss when faced with an unfamiliar type of denial. Through collaboration and education, leaders must develop unique strategies to tackle these varying denial types and appeal them effectively.
During this session, participants will discuss how they approach various types of denials, from clinical validation to Medicare Advantage, private payer, prior authorization, line item, coding-based, and more. Leaders will share their proven strategies to tackle these denial types and the results they’ve seen from their efforts.
Key questions to consider during this session:
• Which types of denials is your team involved with fighting? What part of the process are you involved in (prevention, appeals, follow-up education, etc.)?
• How do you handle Medicare Advantage denials? Are they more challenging than traditional Medicare?
• How do you handle private payer denials versus Medicare or Medicare Advantage denials? Does the process change depending on the payer issuing the denial?
• How do you handle clinical validation denials? Is a physician involved with the appeal process? Do you clinically validate at-risk diagnoses on the front end to avoid denials on the back end?
• How do you handle prior authorization denials? Do your approaches differ based on payer, procedure, etc.?
• When it comes to coding-based denials, do you involve your HIM/coding team in discussions and appeals? What does the process for handling those denials look like?
• What is your strategy for addressing charge/line item denials?
• How do you handle medical necessity denials? Does your process differ from other denial types? Do you involve different departments or individuals?
DISCUSSION GUIDE #3
Reporting and Tracking Denials
Session Moderator:
Nicole Votta, NAHRI Director
Synopsis
When it comes to effective denials management, knowing your organization’s denial trends is critical to long-term success. Metrics can help CDI and revenue integrity leaders understand where to focus their resources for the biggest return on investment, show them where efforts are paying off, and illuminate areas where they could improve. Knowing what to track, how to collect the data, and what to do with it, however, can be a full-time job on top of an already full leadership plate, so leaders must carefully determine how to use their limited time and resources effectively.
During this session, participants will discuss the types of metrics they track and why, how they track denial trends, the current trends in their denial data, and, perhaps most importantly, how they are acting on those trends.
Key questions to consider during this session:
• What data does your organization track for denials? Do you track denials by payer, volume, service line, overturn rate, amount recovered or amount lost, reason code, etc.?
• If you are tracking denial trends, what are you doing with that data? How is it being shared and used?
• How are you tracking your denial data? Is it done manually in a homegrown tool or spreadsheet or through prebuilt software? What challenges has your tracking method posed?
• What are some of the trends you’ve seen in denials over the past 12 months? Are certain payers issuing more denials? Are certain procedures or service lines more likely to see denials?
• Have you taken any steps to amend contracts with payers based on the trends in your denials data? What did that process entail? What departments were involved?
• Have you taken any action regarding provider education related to denial trends? If so, how have you worked with providers (e.g., group versus individual setting, formal versus informational presentation)?
• If certain diagnoses are being denied more frequently, have you created organizational clinical guidelines for providers to use? If so, have you seen a resulting impact on your denial volumes related to those diagnoses?
• As you’ve modified denial prevention and management practices in response to data gathered, have you seen the data change as a result? What changes have you observed over time?
LIGHTNING ROUND
DRG Downgrades: What’s Lurking in Your Revenue Cycle?
Presented by: Kristine Green, MSN, RN, vice president of clinical documentation at Northwestern Memorial HealthCare in Chicago, IL
In this presentation, Green will describe why DRG downgrades can be a hidden source of revenue loss and provide an overview of a novel multidisciplinary approach to evaluate DRG downgrades and write appeals. Attendees will learn the steps necessary to create a strong denials/appeals program with frontline clinician presence, as well as build a coordinated effort with key revenue cycle team members.
Denials Tracking and Reporting
Presented by: Ashley Wilson, CMC, CRC, executive director of PFS at Roswell Park Comprehensive Cancer Center in Buffalo, NY
In this presentation, Wilson will discuss key items for tracking and reporting denials in efforts to recover cash, identify trends, and making the data actionable for system or process optimization. In addition, she will discuss some best practices approaches for monitoring the status of your denials and tools for the staff.
PARTICIPATING LEADERS
KORY ANDERSON, MD, FACP, CHCQM Senior Medical Director of Intermountain Physician Advisor Services, CDI, & Acute Quality Intermountain Health/South Weber, UT kory.anderson@imail.org
TINA BUI, MBA, PMP, CHFP, CRCR, LSSGB Reimbursement Integrity Manager Children’s Colorado/Houston, TX tina.bui@childrenscolorado.com
KAREN ELMORE, RN, CCDS Program Manager for CDI & Physician Engagement & Education BJC HealthCare/St. Louis, MO karen.elmore@bjc.org
MICHELE BEAR, DBA, MBA, CHRI, CRCR, CHC, CPC Executive Director, Revenue Integrity, CDM, RCAR, QA, & Team Member Engagement Baptist Health Jacksonville/Jacksonville, FL Michele.bear@bmcjax.com
FRANK CANTRELL, CHRI System Director, Corporate Revenue Integrity Penn Highlands Healthcare/Madison, AL fdcantrell@gmail.com
ANNE ESPINOZA, RN, BSN, CCDS, CDIP, MBA Executive Director Froedtert Theda & Medical College of Wisconsin/Milwaukee, WI Anne.Espinoza@Froedtert.com
KATIE BOYKIN, BSN, RN, CHRI Director, Revenue Integrity WakeMed/Raleigh, NC kboykin@wakemed.org
TONYA E. DEMYON, RHIT, CCS, CDIP CDI Manager WVU Medicine/Fairmont, WV tonya.demyon@wvumedicine.org
JULIE FENTON, RN, BSN, RRT, CCDS Senior Director of Clinical Operations St. Mary’s Healthcare/Amsterdam, NY fentonj@nysmha.org
PARTICIPATING LEADERS
RHODA GALANG, RHIA, CDIP SW Corporate CDI Manager Scripps Health/San Diego, CA galang.rhoda@scrippshealth.org
CRAIG HAMILTON, CPC Director of Revenue Integrity Lifepoint Health/Brentwood, TN hamil022@gmail.com
KELLI HOWARD, MS, CRCR Senior Manager Revenue Integrity Mayo Clinic/Phoenix, AZ howard.kelli@mayo.edu
JENNIFER GARDINER, CPC Senior Director Revenue Integrity University of Maryland Medical System/Baltimore, MD jgardiner@umm.edu
JEN HAYES, MHA, FHFMA, CHFP, CHRI Director of Revenue Cycle Integrity Lexington Medical Center/West Columbia, SC jshayes@lexhealth.org
PENNY JEFFERSON, MSN, RN, CCDS, CCDS-O, CDIP, CCS, CRC, CRCR, CPHQ, CHDA CDI Manager UC Davis/Sacramento, CA pjefferson@ucdavis.edu
KRISTINE GREEN, MSN, RN Vice President, Clinical Documentation Northwestern Medicine/Chicago, IL kgreen@nm.org
SUZANNE HERZINGER, MBA, PESC Managed Care Analyst Oceans Healthcare/Plano, TX suzanne.herzinger@oceanshealthcare.com
SYDNI JOHNSON, BSN, RN, CCDS Director of Education for Clinical Documentation & Denials Banner Health/Tucson, AZ Sydni.Johnson@bannerhealth.com
PARTICIPATING LEADERS
MARY MASTRANDREA, RN, CCDS System Director CDI-DRG Appeals Catholic Health/Melville, NY Mary.mastrandrea@chsli.org
CATHERINE PESEK BIRD, DO, MBA, CHQM-PHYADV Physician Advisor Lakeland Regional Health/Lakeland, FL catherine-pesekbird@alumni.nd.edu
EMILIE NAVIDAD-MCDERMID, BSN-RN, CCDS CDI Director UI Health/Chicago, IL enavidad@uic.edu
KAYLA VANDERBILT, MBA, CRIP, CRCR Director Revenue Integrity & Optimization Trinity Health/Livonia, MI kayla.vanderbilt@trinity-health.org
ASHLEY WILSON, CMC, CRCR Executive Director of PFS Roswell Park Comprehensive Cancer Center/Buffalo, NY ashley.wilson@roswellpark.org
ACDIS INTRODUCTIONS
Linnea Archibald is the associate editorial director, publications and membership, for ACDIS. She oversees the management and strategic development of the ACDIS Leadership Council and associated Mastermind groups, including membership recruitment and engagement, and day-to-day offerings. Archibald is responsible for the strategic planning of ACDIS’ publications, including the CDI Journal and CDI Strategies, works closely with ACDIS’ Diversity and Inclusion Committee and Chapter Advisory Committee, and is responsible for the oversight of ACDIS' local chapters and networking groups. She hosts the “Leadership With Linnea” series on the ACDIS Podcast and is responsible for planning and producing the show. Additionally, she handles the strategic oversight of ACDIS’ social media presence.
Karla Kozak is the editorial manager for products and events, at ACDIS. She edits and oversees the development of all ACDIS book titles, including the ACDIS Pocket Guide series, as well as the content on ACDIS PRO. Kozak is the chair of the Events Committee and works closely with its members to plan the national conference and select the recipients of the ACDIS Achievement Awards. Additionally, she co-leads the Physician Advisor Mastermind and is chair of ACDIS’ Physician Advisor Committee. Kozak also hosts the bimonthly segment “Conversations With Karla” on the ACDIS Podcast, where she is joined by contributors to ACDIS’ most popular products.
Nicole Votta is the director of NAHRI. She ensures NAHRI meets the needs of members and serves as the voice of the revenue integrity profession, and she works closely with the NAHRI Advisory Board. She is responsible for the strategic planning of the association, membership engagement and benefits, and development of educational material. Votta manages NAHRI’s publications, including the NAHRI Journal and Revenue Integrity Insider. She works with NAHRI’s Networking and Events Committee, Education Committee, and Credential Committee. She oversees the NAHRI Leadership Council and Mastermind groups, including recruitment, research, and member benefits.
ABOUT OUR SPONSORS
CorroHealth is the leading provider of clinically led healthcare analytics and technology-driven solutions, dedicated to positively impacting the financial performance for physicians, hospitals, and health plans. With over 11,000 employees worldwide, CorroHealth offers integrated solutions, proven expertise, intelligent technology, and scalability to address needs across the entire revenue cycle. Our global presence extends over 10 locations, including the United States, India, and the United Kingdom, enhancing our ability to deliver exceptional service on a large scale.
www.corrohealth.com
At Solventum, formerly 3M Health Care, we create breakthrough solutions for our customers’ toughest challenges by pioneering game-changing innovations at the intersection of health, material, and data science to change patients’ lives for the better—while enabling healthcare professionals to perform at their best.
www.solventum.com/en-us/home/health-information-management/
PROPERTY MAP
LOWER LEVEL FIRST FLOOR
WEDNESDAY
Round A - D Sessions
WEDNESDAY Round A - D Sessions
PEBBLE BEACH DORAL AUGUSTA
WEDNESDAY Round A - D Sessions
MEDINAH
TUESDAY Networking Reception
TORREY PINES