Why It Matters
Most authorization and charge-related denials have root causes that live in clinical workflow, not in the business office. Preference cards, supply proximity, procedure time pressure, and real-time item selection all shape whether a claim ultimately matches what was authorized. None of this is visible on a denial dashboard.
If clinical staff perceive the RCM leader as an auditor, they defend their process rather than describe it. The real constraints - time pressure, missed breaks, staffing gaps, supply placement - never surface. The result is a denial project that classifies losses more precisely without preventing them.
A common mistake we see: RCM leaders request "a meeting with the OR" to review denial data. The clinical team hears "someone is coming to tell us we're doing it wrong." Access is granted grudgingly, information flows one way, and the underlying workflow issue remains untouched.
Key Takeaways
- Secure explicit leader air cover before requesting clinical access. Without a senior sponsor conveying the mission, clinical departments have little incentive to grant meaningful time.
- State plainly, and more than once, that the visit is not an audit. Repeat it to leaders, charge nurses, and individual staff.
- Plan for a full week of observation, not a single visit. In this episode of RCM Reframed, Sergio Quiej described spending a week in surgery across ortho, general surgery, and other case types so that by the time his target case arrived, staff had already grown comfortable with his presence.
- Observe silently at first. Take minimal notes in the room. Value comes from watching item selection, supply proximity, timing pressure, and deviations from preference cards.
- Use open, non-punitive questions. Sergio's "if you had a wish for Christmas in July, what would you want?" produced consistent, honest answers about staffing strain that connected directly to the denial root cause.
- Frame findings around helping the clinical team, not correcting them. The business case for change becomes shared rather than imposed.
- Translate observations into a solution that preserves revenue and reduces clinical burden simultaneously. This is what earns future access.
Expert Perspective
In this episode of RCM Reframed, Sergio Quiej, Patient Financial Services Support Manager at Adventist Health, described how he investigated a category of authorization denials tied to implant sizing. Dashboard analysis told him what was denying and why the payer rejected it, but not why the wrong-size item was being used in the first place.
He requested time in the OR. That request took leader support to approve. Once inside, he made a deliberate choice: "I'm just here to observe. I'm going to observe and maybe create some notes, that's it. It's not an audit at all, believe me. And I had to make sure that that came across, that it wasn't being punitive."
He spent a full week across different service lines before focusing on his target cases. By the time he was watching the specific procedure type driving denials, staff had already seen him for several days doing nothing but observing. His presence was no longer novel or threatening.
The root cause emerged from a single open question: what triggers you to select one item over another? The answer was time pressure and supply proximity. Under a time constraint, clinicians grabbed what was closest, which sometimes differed in size from what had been authorized. No dashboard would have surfaced that.
The observation also produced a second insight. When Sergio asked staff what they wanted, the answer across roles was consistent: more help, enough to allow breaks and lunch. That answer connected directly to the denial pattern - a floater role would reduce the time pressure driving item mis-selection - and became the basis for a 1.5 FTE business case that the surgery department itself later submitted.
The pattern is worth naming: access earned through non-audit framing - honest information, root cause identified, and a solution that serves both clinical and financial outcomes.
