Last year, a federal audit of Medicaid managed care organizations (MCOs) found that one out of every eight requests for the prior authorization of services in 2019 was denied and that most state Medicaid agencies did not routinely review the appropriateness of a sample of MCO denials.
MetroHealth, a non-profit public healthcare system with four inpatient units, four emergency departments, and over 20 ambulatory locations, stated that a lack of integration between systems often causes unwarranted denials. “Identifying common causes of claim rejections is typically a manual and time-consuming process,” MetroHealth acknowledged in a statement.
Ohio-based MetroHealth tackled this problem by working with Cognizant, a New Jersey-based information technology services and consulting company. By examining the entire revenue cycle, an automated solution was implemented, which decreased denials by 30 percent.
Healthcare Innovation recently spoke with MetroHealth’s Eric Cercone, director of patient access, and Scott Schell, M.D., Ph.D., chief medical officer with Cognizant.
To answer the question of why MetroHealth decided to work on this automation project, Cercone clarified that MetroHealth had worked with Cognizant for years and that utilizing automation has been able to do more with less. As a safety net hospital, Cercone explained, “We don't have the robust budgets that some of the other organizations do. So, the ability to automate…allows us to continue to stay afloat over these challenging times within healthcare.”
“Their return on investment has always been successful,” Cercone said about the partnership with Cognizant.
“I know MetroHealth very well,” Schell interjected, “this is an incredibly important asset in our geography.” “It’s a county-owned and managed hospital that does really outstanding work in primary care and health maintenance with predominantly a Medicaid population, completely unheard of in most other places.”
“The biggest thing that we did,” Cercone said, “was partner with them to utilize their technology and expertise to help identify the denial trends that we saw growing across all payer categories.” Cercone mentioned that MetroHealth saw a growth in payer rejections over the past decade. The denials were centered around all different aspects of the revenue cycle, he explained. Cognizant allowed MetroHealth to investigate the root cause of denials, Cercone noted. Then, changes were made within Epic, MetroHealth’s Electronic Medical Records (EMR) system.
“Payers just don’t want to pay claims,” Cercone responded to the question of why the denials were growing. “They've put in more restrictive policies around coding requirements,” Cercone added. “A lot of them have started to put in policies around unspecified diagnosis codes.” And, Cercone noted, “physicians aren’t supposed to be coders.” “One of the things that we're working on is provider-facing audits at the front end to identify opportunity and present that directly to a clinical person to actually perform the clinical service and allow them to be able to make those corrections.”
“The depth and breadth of complexity of policies and benefits is really quite incredible,” Schell added.
The automation project has made the administrative work more efficient, Cercone stated. “We’ve been able to decrease the overall volume of work.” “Staff are able to get to … the more impactful accounts.”
One of this project's biggest challenges was finding time to put the processes in place, Cercone shared. “It’s a lot of data and a lot of information,” Cercone remarked. It took time for Cognizant to understand Ohio Medicaid requirements, Cercone explained.
“Don’t be scared to continue to try new things and adapt to technology,” is Cercone’s advice. “You have to be on the cutting edge.”
“Automation,” added Schell, “is absolutely crucial in today’s market and environment for basically preventing denial of claims before they occur.” Schell advised working collaboratively to create optimal workflows.
Looking ahead, Gen AI automation is on the horizon, Schell shared. Later this year, updates will be released to help practicing clinicians.
