MedPartners CDI Outpatient Denial Risk

Reduce Denials & Minimize Risk in Outpatient Clinical Documentation Integrity (CDI)

The key to success in denial reduction in the outpatient (OP) environment stems from the knowledge of the factors that contribute to risk.  Denial reduction begins with denial prevention, which starts with an understanding of the revenue cycle and the areas of greatest risk. 

Due to the vast number of outpatient settings, denials reduction in the office setting will be the emphasis.  The office setting, like all healthcare settings, should not work in a silo.  Every person within a healthcare setting has one focus and one focus only – the patient.  Beginning with that focus in mind, the office is off to a successful start. 

Scheduling & Practice Management Systems

Scheduling is the first area of potential risk because information gathering begins here.  An increasing number of practices utilize Practice Management System (PMS) software which carries the burden of the majority of the administrative workload.  Ensuring the correct patient demographics are obtained initially and then confirming with every visit will help eliminate any areas of missed communication.  The insurance information is typically taken during scheduling and it is recommended the information be repeated back to the patient for confirmation.  Through a list maintained in the office or on an updated PMS, the scheduler will be able to inform the patient if the provider is in or out of network, and of any co-pays that might be due at the visit.   

Patient Registration

At registration, copies are usually made of the insurance card, and the office staff should take this opportunity to double check the information from the card against the medical record and/or PMS.  Small errors made during scheduling and registration, such as transposition of a birthdate or SSN can trigger a claim rejection which would require additional time to correct.

If there is prior knowledge of a procedure that requires pre-certification or prior authorization, the staff would confirm medical necessity with the provider and ensure that the proper forms, such as the Advance Beneficiary Notice of Non-coverage (ABN) are completed and the patient is notified of any additional cost on their part.  There are several integral steps in pre-certification and prior authorization and it is crucial to follow the process exactly in order to avoid financial penalties.  

Documentation vs Risk

Documentation is another area of risk and while there are several moving pieces, there are also easy fixes.  The provider should understand that while the focus is on the patient’s health status, it is essential to document every thought, concern and possibility surrounding the management of all possible and confirmed conditions and diagnoses.   Not doing so could display gaps in documentation of the encounter and might trigger a denial for incomplete documentation. 

Once documentation is complete and precise to the best of the provider’s knowledge, ensuring accurate coding and charge capture can also minimize risk.  Accurate coding and charge capture begins with ongoing comprehensive education on the large number of guidelines and rules which are utilized in the OP environment.   If pre-numbered encounter forms are utilized, they should be reviewed and updated whenever necessary.   

Claims Software

The claim software also should be reviewed as often as necessary for any contract and fee schedule modifications based on determinations, rules and guideline changes.  The claim form is one area where hard stops might be necessary in order to avoid simple errors that could result in a rejected claim.  Using a PMS to implement hard stops can help in alleviating the repetitive task of reviewing the claim form. 

Finally, having a process in place for Accounts Receivable (A/R) will assist in timely payments toward a zero balance with few write-offs.  Automating the process within a PMS will allow for timely and accurate communication between all parties, the office, the payer, and most importantly, the patient. 

In summary, having processes in place in each of these high risk areas will greatly reduce denials and minimize risk in your facility.  We are ready to assist you with a comprehensive review of your outpatient revenue cycle in order to set you up for the success that your patients deserve. 


Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-O

Mid-Revenue Cycle CDI Content Manager