Q&A: Denial management teams

Q: What guidance do you have for building a denial management team?

A: As with any team, it is important to have the right players working together with identified roles and responsibilities established for each. The members of the denials management team should be representative of departments with a direct tie to the various types of denials. Include the following groups:

• Admitting/registration
• Case management
• Patient financial services
• Nursing
• Health information management (HIM)
• Information technology (IT)
• Finance
• Compliance
• Physicians

For large facilities or large provider groups, establish several layers of teams. A typical hierarchy would resemble a pyramid. At the top would be the leadership or steering committee consisting of executive or senior-level members. These team members will be presented with the denial statistics and make or approve recommendations from the denials management team. At this top level that the compliance officer and physician chief of staff would be involved. The physician advisor would likely sit at this level but may also attend the working group meetings if needed.

The second layer would consist of managers or directors of the different departments driving the denials management initiatives. This would be considered a working group, vetting out the data supplied by the teams, identifying the root cause(s), and proposing solutions to be presented to the executive team. Of course, the entire process would begin with the team or staff actually working the denials in your organization. Although they may not sit on either of the two official denial committees or teams, this group consists of key staff from case management, denial or appeals unit, business office, coding, CDI, and medical records.

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information, see Medicare Compliance Essentials Training Compendium.