Hold Onto Your Money From High-Dollar Claims
Inspire your team with tips to keep funds in your practice’s pocket. With almost $20 billion being spent annually disputing health insurance claim denials and an average of 14 to16 percent of claims being initially denied (which is increasing each year), the need to implement a workflow to stop the loss of these funds is at an all-time high. In their HEALTHCON 2025 presentation, “Implementing & Mastering High Dollar Workflows to Improve Your Bottom Line,” Catherine Keegan, BSBM, CPC, CPCD, CCSP, RCMS, and Holly Ridge, BSN, RN, CPC, CPMA, shared tips on how to help your practice keep more of your money from these high-dollar claims. Continue reading to see how their expertise can benefit your organization. Determine Your Parameters When you are setting the appropriate parameters for your practice to determine what is considered “high dollar” for you, you’ll first need to identify the baseline dollar value based upon the average charges of your practice. You will want to look at the top 10 to 20 percent of all charges for your average week. You may wish to carve out specific CPT® or HCPCS codes, drugs, or supplies that are considered high cost to the practice; or, focus on specific services that most commonly go unpaid. Assemble Your Team When it’s time to assemble your team to work on these high-dollar claims, Keegan gave a specific list of desired employee traits and expertise for the practice setting: Desired Traits Expertise “The person you choose has to be very assertive. And that’s not to be confused with aggressive,” said Keegan. “We don’t want to tick off our payers. So, there’s a fine line, because if they annoy them, they’re not going to get anything.” Having a problem-solving and innovative mindset is crucial for team members. Certified coders are ideal for this role due to their advanced expertise, particularly those with extensive clinical knowledge. “Normally your higher-dollar claims are going to be denying for medical necessity, so you’re going to want coders in this role,” said Keegan. Having an employee with the right set of skills in this position will increase your cash flow and decrease revenue leakage. For the health system setting, the traits and desired level of expertise changes slightly, according to Ridge: Desired Traits Expertise “You want to find the folks who are passionate and really feel that this money is their money. The type who are going to really push to get every penny back in the door of their health system or practice,” said Ridge. She added, “It might help a lot to have an SME [subject matter expert] for a certain payer. That way, you have someone who is the expert for those payers and their policies.” Establish Your High-Dollar Workflows Every good team needs a leader. When you start working on these high-dollar workflows, you will need to choose someone to lead the team. They will act as project manager and establish a sense of accountability for all other members of the team. This person will also be in charge of keeping other team members excited and engaged. Clearly identifying the roles and responsibilities of all members is important for keeping everyone on task and working as one cohesive unit. “You need to assign a project manager and check on the accounts roughly every two weeks to capture any new incoming accounts. Every team member should understand their individual role clearly,” Keegan said. Your high-dollar workflows should be structured around claim submissions, denial responses, and lack of response follow-up. You want to call on high-dollar claims early on to find out if the payer needs anything from your practice. Don’t wait until the final day of processing to see if it was denied for something that was easily preventable, like missing medical records. “If you send medical records, even if you send them certified with a return receipt, or if you use a portal — call them. Confirm they have received those records and take down that call number and reference number — because it is amazing how many times they lose those records,” said Keegan. Keep Stakeholders Engaged It’s important to keep people like your stakeholders involved in the process. “Your stakeholders can even be your physicians. I know a lot of physicians who are interested in their AR [accounts receivable], in their money, and in their revenue leakage. So, if you have an active physician, pull them in,” said Keegan. These stakeholders are going to look for things like volumes and dollars of outstanding high-dollar accounts, which should include new inventory versus baseline numbers. Also, highlight the percentage of successful outcomes from resolved accounts. Point out big wins, any special circumstances like an abnormally high-dollar account, or something like an old account that was finally resolved is a big win, too. Maintain Positive Energy With a high rate of burnout in this area, it’s important to keep morale up within your team. Don’t feel defeated by small losses or setbacks, but use them as learning opportunities instead. Teach everyone to win and lose as a team — don’t blame anyone. Remember that maintaining the team’s momentum is paramount to the continued success of the team as a whole. Mention good news and wins during team meetings, and in team chat interactions. “Valued staff are engaged staff,” said Ridge. Continued success offers you a chance to expand your team later on with increased revenue. If you feel your staff is less engaged, Keegan said, “A few times a year, sending ‘thank you’ cards to their houses makes a huge difference as well.” Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
