Date of Conferral

2016

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Sue Bell

Abstract

Health care reimbursement is changing, and hospitals are finding it difficult to receive payment due to insurers' denial of services already rendered to patients. A denial can be considered an underpayment by the insurer to the hospital. Using a Six Sigma approach, a large hospital system in the southeast United States found that individual hospitals were not focused strictly on denials, but other tasks as well. Hospital administrators conducted a literature review and found that centralizing denials management team has improved reimbursement outcomes elsewhere. Therefore, the hospital system implemented a centralized denials unit to focus on overturning insurer denials while the patient was still hospitalized. The purpose of the project was to develop an evaluation plan to determine whether the pilot centralized denials management unit could overturn an additional 5% or more of the concurrent denials compared with the current individual hospital-based denials management approach. The quantitative evaluation plan will guide review of data collected from one organization to determine payer trends on the types of denials received and reasons for the denials. Understanding the pattern of denials is expected to uncover opportunities for denials coordinators in the dedicated centralized management unit to challenge payers based on contract language or medical necessity. If the centralized denials management unit is shown to reduce denials, it will be considered for expansion corporate wide. The social change expected through a successful denials management unit program is that the hospitals in the system will recover payment for services rendered and will be able to continue to provide quality care in the communities they serve.

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