Custom solution addresses denials dilemma for Gillette Children’s

For many health care providers, denials—a refusal of carrier payment for services—are a pervasive feature of the revenue cycle. Tracking the where the when and the why is a daily challenge, but it’s essential to recapture lost revenue.

Ashley Karlen, vice president of revenue cycle at Gillette Children’s located in St. Paul, Minnesota, can attest to that. Her organization, a nonprofit pediatric care facility specializing in brain, bone, and movement conditions, was challenged with consolidating various data streams resulting in hours and hours of report compiling and limited denials analysis. She knew there had to be a better way. She reached out to RSM US LLP for help, and it just so happened RSM had a custom solution just right for Gillette. “This was something we’d never seen before.”

After evaluating Gillette’s challenges and learning of their specific denials management needs, the RSM team presented a solution that could address their consolidation issues and provide custom reporting.

“We were excited after seeing RSM’s denial’s solution,” said Karlen, adding, “It allowed us to get reporting by the payor; on a three-, six- or nine-month basis; by medical service type, and more. This was something we’d never seen before. I was able to show our executive leadership how we could identify denials immediately and save hours of time.”

Delivering the must-haves

Karlen indicated the hospital also needed the denials management tool to identify the specific medical service type information, such as spine patient services. Unfortunately, claims for these types of services all fell under the more general outpatient billing segment in the past. Therefore, the ability to drill down on this granular information to identify actionable insights would be a must-have for Gillette’s ability to serve the unique needs of its pediatric care population. Message heard by RSM. A custom-built solution was provided and with one click, the medical service type was revealed.

“We’re a specialty children’s health care provider with specific services and an out-of-the-box tool was not going to work for us,” said Karlen. “We needed a custom solution unique to our needs and RSM understood that.”

Meaningful outcomes

It’s now been two years since the implementation of RSM’s denials management solution and according to Karlen, the organization has seen meaningful progress.

As for the wasted time formerly spent in data sorting, sifting through spreadsheets, and manual report compiling, Karlen indicated now her team has time to address more strategic initiatives or do further analysis. For example, a member of her team recently examined prior authorizations that on the surface appeared to be a low volume of denials; however, stretched over time, the total of denials was significant. The team member evaluated the issue and identified a simple fix.

“This was not something we could have done previously to using RSM’s denial management interactive dashboard,” Karlen said. “It’s our No. 1 tool to address denials management.”