Welcome to Deny This, a pair watch podcast where you'll find real stories, expert insights, and strategies for providers. Join us in the fight to fix a broken denial system. Hey, folks. Welcome to Deny This. This is the national podcast for, all things related to denials and appeals for both providers and patients. We're pleased to have today two of our guests, who I know extremely well, Doctor. Kendall Smith and Reggie Allen. Both are absolutely, experts in their field, national thought leaders on clinical and technical denials, and we're thrilled to have them. So today we're going to talk a little bit about denial data and how that can provide actionable insights. They recently did a webinar that you can find on YouTube or on the Payer Watch website and the ADAM website. So specifically, I'd like to introduce Reggie Allen, if you could tell us a little bit about your background how you came to be on this podcast. Great. Good evening, everyone. My name's Reggie Allen, and I am a registered nurse. I have an extensive background in clinical denials and appeals. Very interested in that and working with our clients that we have to overturn as many denials as we can to moving from denial management to denial avoids. And obviously we're trying to do that with the use of data that we presented, looking at data analytics make changes. Great, I'm gonna come back to that in a minute. Doctor. Smith, if you could tell us a little bit about your background. Sure. Kendall Smith, Chief Medical Officer for PayerWatch, a hospitalist by training with background in utilization review and CDI. I've been working with Reggie for many years, Brian for over a decade. I think Reggie and I are here today as is Brian ultimately with the goal of putting ourselves out of business. We've always believed as a company and I've thought personally that if we could take actionable data and translate that into process improvements and prevent denials, that the denial industry would dry up. That's obviously a little bit of wishful thinking. But Reggie has tremendous insight for those of you that listen on the webinar. And we're here today to follow-up on that. Good. Well, as a matter of fact, we are Reggie, I really want to bring it back to you and you talk about how to make denial data actionable. And if you could just in a couple of words and maybe a paragraph or so, let us know what are your thoughts about how to make that data actionable? I've always been a big believer that information's fine, but action is better. So how do we turn that information into knowledge and knowledge into action? Right, Brian, I think the way we actually approach this is actually better understanding what the root cause, which is the key, having a great taxonomy that we're able to use, that we're all speaking the same language, as well as understanding what the root cause is of the denials that we're receiving that by payer, understanding some of the system and process issues that facilities may be having that generate these denials. And so without bringing actionable data to the table and especially actionable data, it's impossible to be able to make those changes and to mitigate these denials. So in other words, it's almost like executives, show me the proof. Show me the money. Sure. Yeah, okay. Yeah, I mean, see that a lot with process improvement, working with physicians, Brian, where coming in with an anecdote, you're gonna get shown the door. And when you walk in with objective data, you're going to get much more engagement and willingness to talk and implement change. And I think the one thing that Reggie has done tremendously well is to deliver granular data that allows actionable change. Early in my career was shown the door many, many times bringing in one off stories and learned early on the value of data in engaging physicians and driving leadership change. And I think that's something that Reggie's done phenomenally well and I'm glad to be here today. Well, part of it is make sure you don't go in empty handed and that you can provide a reference and a citation to everything you show. Absolutely. Well, think Brian, I think one of the other things that Reggie taught me early on, and I put all of my trust and faith in this man, is almost as bad as going in with data. And when you do enter a room with data, you're often walking into a lion's den. Reggie, I think you can attest to this that people are going to start trying to poke holes in it. And the moment they can poke a hole in something, your credibility is shot. So having bulletproof data, first and foremost, I think has gotta be an absolute best practice. I agree. I go back to the days of clinical pathways and outcomes management in trying to convince physicians that we've normalized your data so you are like everybody else, because early on, when I was in data analytics, they always talked about, no, my patients are sicker. That's why my results are different. Like, no, we've actually normalized all that, so it's an equal comparison. So I agree with you there. If I could, let me get to a couple of the questions that we have well over two fifty attendees and Reggie, great job. Everybody, comments were wonderful, they came back on that data into actionable insights webinar. But here's the first, I think big question, and if you could both could discuss this. How do we best manage denied claims for lack of medical necessity despite a peer to peer being done, set up, conducted on the front end and showing an approval with an off letter? The payer is re requesting the medical records and additional information after the approved peer to peer. I think that's a great question. And so what I would say to that is we know that many times that the peer to peer is done, that there are still denials after we receive that process. So there's a couple of things that I would like to remind everybody. First of all, even though it gets, you got it overturned peer to peer, you need to make sure that that information that you provided to the payer or to the physician that you did the peer to peer, that you send that in in writing. Some of the payers are very specific that even though overturned on the phone, they need that data. The second thing I want to remind everybody is that for the MA plans, keep in mind that once, according to CMS 4201F, as long as once you get an authorization on a case, it cannot be denied unless there's a change in the patient's medical condition or there's fraud and abuse. So you need to be able to quote that even when you write your appeals of the CMS four thousand two hundred and one F that really explicitly states that about when you've already received approval on a case. Well, it's interesting you just mentioned that. You thought it was important for a clinician to embed regulatory content in an appeal. Absolutely. Just to underscore, here are the rules, etcetera. Doctor. Smith? Yeah, absolutely. We see time and time again, auditors coming back for a second bite at the apple. As Reggie succinctly put it, once an appeal or an authorization is granted upfront for services, absent fraud or a good cause for reopening, that case can't be looked at. Reggie and I look at cases on a daily basis where approvals were granted and a contracted auditor who may not be aware of that approval, either intentionally or unintentionally shows up and asks for the chart for review and then issues an adverse determination. It's up to the hospital, to the clinician who's responding to be informed of their rights much like a person would need to be informed of the Miranda rights, realize they exist, be able to recite them and be able to push back against that auditor's unfair processes. Speaking of unfair processes, and let's stick with MA plans just for a moment here. I know there's a bane of many physician advisors all across the nation, but how would you handle an MA plan denial when the payer's making up their own complex medical factors and denying despite you outlining every complex medical factor present? How do you do? They're all making it up. What do we do? So the first thing, it's a Medicare case, if the patient's a Medicare Advantage, you need to make sure first they have to comply if there's any clinical criteria that's available with NCDs and LCDs. You can't make up your own. In those cases where the NCDs or the LCDs are not available or there's no clinical criteria available, you can use other guidelines and methods to other guidelines from other sources like INNAQual or MCG. However, you have to make that information available to the public, to the facilities so that they can review those. So you can't just do something blanket. You have to it's all required now under the regs that you the criteria that you use has to be made available and it can be used. And I think the other thing that I think Kendall would be a great one to speak about is how you need to look at the patient holistically and not just looking at one single guideline because most of the patients have more complex problems and conditions. Yeah. There is an art to having that conversation and synthesizing the information. There will be calls and I've had them where you're just going to agree to disagree. If you feel that the plan, as Brian said, is making things up, off roading, inventing things. At that point, I generally will agree to disagree, memorialize the disagreement in the record and then file a complaint. Look to escalate it. If it's Medicare Advantage, send it to CMS. If it's a different type of plan, send it to the state insurance commissioner. The insurance companies have a responsibility to consider full information and act in a reasonable factual basis. And if they are inventing things that don't comport with how medicine's practiced, then they need to be held accountable by a third party and third parties exist just to do that and look to bring an adult in the room at that point. It's interesting you mentioned that. We talk about the power of the information. And Reggie, when we talk about especially tracking payer behaviors like you just described with, of using coding clinics that are no longer in practice, of using criteria, Framingham criteria from the late 70s, mid 80s to a judge heart failure and shock. And so how do we actually capture all of this payer behavior? Because to my point, Reggie, I think this does become the data and the information that need to make it back to the C suite and possibly even to managed care contract. How do we collect and track the payers' behaviors and make sure that gets back not just to the payer, but also to the folks that can do something about it? Yeah, I think it's important. And what we learned from the meeting that we provided is that a lot of the hospitals don't really have a good denial management software system that allows them to capture this information. It's going to be very impossible or not impossible, but it is somewhat difficult to be able to aggregate all this data and information if you don't have a good denial software system that allows you to know when the appeals were sent, when they're getting back, you will be able to track it by CPT codes and ICD-nine codes. You need to have some sort of denial software system that strictly collects all of those elements and then to be able to report it back and to take them to payer escalation meetings. So what we're seeing is a lot of people are actually just doing things off spreadsheets, but they don't have the granularity that they need to be able to go back to answer the questions that the payers are asking for. Yeah, I do know in speaking with many hospital system executives, the challenge of getting the right information back to the managed care department or to the CPE, specifically outlining and with very detailed precision, here's what's happening. So Doctor. Smith, you've always talked about forwarding things to dispute resolution and escalation, But to me, takes a very detailed, strong and tight information. Can you talk about that? Oh, absolutely. I think the worst thing is to show up at a dispute resolution meeting or they cross the table from a payer with what you believe to be a viable data set. Call them out on, Reggie might have pointed out a failure to respond in a prompt timely fashion, and then get pantsed. I've been in those meetings, I've been on the receiving end of being pantsed where the payer immediately was able to look at the data set and said, no, no, actually you're wrong there. Have the twenty cases you've talked about because they're going to come to these meetings prepared and they're going be ready to defend themselves. So you need to be darn sure about the data set that you're bringing and the narrative that you're bringing to the table, because that's going to have been vetted in advance by the payer rep or their counsel. So you do need to have complete and reliance in what you're holding. Yep. No, no, I agree with that. It's a sinking feeling when it happens. Well, I think when I first got into this business many, many, many years ago, one of my mentors indicated me, and this goes back to the days of walking into a hospital or into a meeting with the payer or a dispute resolution meeting with a two foot stack of green bar paper, and being able to show the judge, I've got every transaction here. And so in his, he who has the best documentation wins. Absolutely, always. And so the accuracy of the documentation sounds like it's really important in capturing it in a methodical, systematic way, whether it's denial management system or an appeal management system, sounds like that's the way to go. But especially if you're presenting it back to payers. So any final thoughts, Reggie, about how important data is to provide actionable insights, especially in denials and appeals? Like I say, I think the biggest key that I've seen and with organizations is really just having the data and the right elements to be able to show. You can't go in empty handed. You need to make sure the data is accurate. But it's also understanding the elements that you actually need that that actually paints the picture of the fact that, yes, here's the denial. Here's when we received it. Here's the hospitals need to understand the outcomes of them. Also understand and then to be able to we'll help them work through not only dealing with the payer, but again, also looking at systems and process issues that they may have that's creating these denials. I think you just hit the nail on the head. One of the things that's amazed me from working with you is your ability to take that data that we've been talking about here in an abstract way and get it down to a specific pain point in the hospital. For example, looking at denials by day of the week, and attributing an uptick in denials on Saturday or Sunday to understaffing in a hospital's UR department and actually being able to quantify how much that understaffing is costing that hospital in terms of the denials, the access to number of denials you're receiving compared to Monday through Friday. So being able to tell that story, which you do at a phenomenal level and have really educated me on. And the ability not only to go externally to talk to payers, but to drive process change internally in an educated informed way has been eye opening for me in the latter parts of my career. I really, it's amazing the insight you can get into hospital operations from working the back end of the revenue cycle. You can see where authorizations are falling off. You can start to see where understaffing is leading to an erosion of revenue. All sorts of things that can be focused internally. So the last thought that I want to leave the both of you with and have you comment on is the belief that we as denial and data specialists, right, we're experts at this. We always seem to feel like we have to have the dollar sign in there when we're presenting this back to administration, to the revenue cycle, back to the C suite. The dollars have to be involved. One of the things that we don't necessarily talk about too much in the denial and appeal space is the impact on quality of care. Reggie, I know that I've been in more than one presentation with you, and you say this does impact the quality of care. Can we talk about a little bit, maybe end on the quality of care that we can glean from the denial data and the impact on care that some of these insights, and what can be made actionable from a quality perspective? That's a great question. One of I guess when I when I think about it when we tied into denials, a lot of times what we're also seeing is patients that where there's an expectation that we get authorizations and those sort of things, we actually really need to be treating the patient. I mean, that's what we need to be doing. And so we see quite a bit of denial sometimes where patients come through the emergency room setting. They end up either in the ICU or these patients end up going to surgery. We never got an authorization on them because they were too sick at the very beginning. And so we still have a lot of denials in that space. Doctor. Smith, can denials impact quality of care? Absolutely. To start with, you're looking at revenue to the bottom line. When a hospital is running on a constrained profit margin, start to see understaffing. You start to see, in my opinion, my experience, worse outcomes with tightly constrained hospital systems. And so something as trivial as a forty thousand dollars total knee denial, if that's due to a systemic issue that's not detected across the system may extend to twenty, thirty, forty total knees and a million dollars plus in revenue. Yet million dollars plus in revenue may be enough to provide several new nurses salaries. It may be enough to buy state of the art equipment. It may lead to a lot of things that might not otherwise exist in a hospital struggling with denials. So I view quality outcomes and denials is going hand in hand. And I think they're inseparable. Ultimately, all of these things to me, quality and denials have one common denominator and that is appropriate documentation. A medical record that is focused on quality has appropriate documentation on it, that appropriate documentation then more often than not leads to inability to defend the medical necessity of the care that was provided and an ability of the hospital to fight and overturn that denial ultimately, whether with the payer or through a third party. So I think at the key core of all of that, we're really talking about good documentation being the common denominator across the universe. One of the other comments I think that comes to my mind too, Kendall, now that you bring that up, the other issue that we have to be very careful with denials and quality of care is that sometimes a very quick to discharge patients, get patients out of the hospital because of payment, because the payers may say, you know, the patient doesn't meet continued stay or doesn't need to stay in the hospital. That creates a quality issue because sometimes we're sending patients out premature. Thank you, Doctor. Smith. Thank you, Reggie, for taking the time to speak with us today. You can't deny this, that denial data is necessary for actionable insights as it relates to payer behavior, quality of care, and really sustainability of the healthcare system. So thanks all for visiting today. And Doctor. Smith, Reggie, thank you again.
