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 should be representative of departments with a direct tie to the various types of denials described in Chapter 1. This would include admitting/registration, case management, patient financial services, nursing, health information management (HIM), information technology (IT), finance, compliance, and, of course, the physicians.

For large facilities or large provider groups, it is advisable to 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. It is at this top level that the compliance officer and physician chief of staff would sit. 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, and medical records.

For more information, see Medicare Compliance Essentials Training Compendium.

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