DDBA 9000 Week 5 Practice Application Section Example

What a Practice Manager Could Do Next Week: The Application to Professional Practice Section for a Study of How Office Managers at Small Medical Practices Reduced Insurance Claim Denials, With Every Recommendation Priced and Measured

Student Name

Walden University

DDBA 9000: Doctoral Study Completion

Instructor Name

Month Day, Year

What a Practice Manager Could Do Next Week: The Application to Professional Practice Section for a Study of How Office Managers at Small Medical Practices Reduced Insurance Claim Denials, With Every Recommendation Priced and Measured

Overview

This qualitative study of multiple cases explored the strategies office managers at small medical practices use to reduce insurance claim denials. Four managers at primary care and specialty practices with three to eight physicians in suburban Atlanta took part, and their practices' denial reports and workflow documents were reviewed. Three themes emerged: checking eligibility at the front desk before every visit, reviewing coding before claims are submitted and tracking denials by payer to fix recurring causes. All four managers had reduced their denial rates, from between 11 and 15 percent to between 4 and 7 percent, over two years.

Application to Professional Practice

Each theme bears on work a practice manager directs. Eligibility checks at the front desk prevent the most common avoidable denial, coverage problems discovered after the visit. Coding review before submission catches mismatches between diagnosis and procedure codes that payers reject automatically. Tracking denials by payer turns individual rejections into patterns that can be fixed at the source, such as a payer requiring prior authorization for a test the practice orders often.

The stakes are significant. Tseng et al. (2018) estimated the administrative costs of billing and insurance activities at an academic health system and found them substantial per visit, especially in primary care. Denials add to those costs because each must be investigated, corrected and resubmitted.

Recommendations

[after]

Costs are estimates from the four practices' staffing and the managers' accounts.

Table 1

Recommendations

Sequencing

A practice starting from a high denial rate should begin with eligibility checks, which addressed the largest share of denials in three of four cases, then add payer tracking and finally targeted coding review.

Implications for Social Change

Fewer denials reduce surprise bills for patients and the time staff spend on rework rather than on patients. For small practices operating on thin margins, recovering revenue lost to denials can help them stay independent and keep serving their communities.

Recommendations for Further Research

Future studies could examine practices that failed to reduce denials, since this study included only successful managers, and could measure the cost per denial directly.

Limitations of Application

Recommendations come from four practices in one metropolitan area and may not transfer to practices with different payer mixes. Yin (2018) noted that case study findings generalize to theory and practice analytically, not statistically, so practice managers should test them in their own setting.

Feasibility for Small Practices

All four recommendations can be carried out with existing staff in a practice of three to eight physicians. The largest time commitment, eligibility checks, replaces time front-desk staff currently spend calling patients after denials, so the net cost is lower than it appears. None requires new software if the practice management system includes electronic eligibility verification, which the four practices' systems did.

How a Manager Would Know It Worked

A manager adopting the recommendations should compare denial rates by reason for the six months before and after, since denials vary by season with deductible resets.

Linking to the Framework

The study's framework, continuous process improvement, explains why payer tracking worked: it turned isolated denials into a feedback loop in which each recurring cause was found, fixed and checked. Managers who tracked denials monthly improved faster than the one who reviewed them only at quarter end, a pattern the recommendations build on.

Evidence Trail

Each recommendation traces to a theme supported in at least three cases, following the thematic analysis described in Section 2 (Braun & Clarke, 2006).

References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa

Tseng, P., Kaplan, R. S., Richman, B. D., Shah, M. A., & Schulman, K. A. (2018). Administrative costs associated with physician billing and insurance-related activities at an academic health care system. JAMA, 319(7), 691-697. https://doi.org/10.1001/jama.2017.19148

Yin, R. K. (2018). Case study research and applications: Design and methods (6th ed.). SAGE Publications.