Some payers are changing their care management programs to reflect Medicare’s requirements, such as the "two-midnight" rule. This change affects patient access areas, says Pamela D. Scott, MBA, revenue cycle administrator at Genesis Health System in Davenport, IA.
"Because this rule predetermines the payment methodology based upon the length of stay in a hospital, it is a simple way payers can identify and contain costs for a case," says Scott.
The two-midnight rule dictates that patients are considered "inpatient status" if they remain hospitalized after two midnights. If the patient stays fewer than two midnights, the patient is considered an outpatient. "This sets the clinical condition of the patient as a secondary element," says Scott. "It makes it more difficult to get approval from the payer."
More often, physicians are getting involved in challenging a payer’s decision to deny claims involving the patient’s status. "As more payers accept Medicare’s requirements, it results in more volume for physicians to take on, where it could become a full-time, defensive role for the organization," says Scott.
Patient access helps avoid denials in these ways:
Patient access employees obtain accurate insurance verification and authorizations.
"It becomes more important that patient access provide accurate insurance information and get payer approval ahead of time, so the physician has a better advantage," Scott explains.
At the point of scheduling, patient access staff members call the payer to verify benefits and coverage, and they provide the clinical diagnosis. "We also work with the corresponding doctor’s office to gain additional documentation ahead of time if we are familiar with the payer’s requests," says Scott.
Patient access leaders collaborate with physician advisors and case managers.
If a payer is challenging the level of care, the physician advisor promptly communicates this information to the case management staff. "This allows patient access the [opportunity] for a financial counselor to work with the patient or family if the coverage results in more financial liability for the patient," says Scott.
A denial management team with members of clinical operations and revenue cycle staff meets routinely to review pending payer requests and denial adjustments.
"Recently, we have engaged senior leadership more. Their support has helped the areas prioritize," says Scott.
The department also implemented a workflow management tool that alerts staff of specific payer requirements. (ONTRAC, developed by Chicago-based Huron Healthcare).
"In taking this approach, we have seen a 30% decline in overall denials from Q1 of FY 2013 to Q1 of FY 2014," Scott reports.
Increasingly, payers require requesting or referring providers to have specific procedure codes authorized.
Teresa L. Brooks, senior director of patient access at Conifer Health Solutions in Detroit, says, "They will deny services if anything other than the specific authorized procedure code is billed on the claim."
To address this new requirement, patient access leaders implemented the "Direct Partner" program. The Financial Clearance Center is now responsible for obtaining authorization for all diagnostic imaging services prior to scheduling the appointment or immediately afterward.
"In the past, we had to rely on the referring provider office staff to obtain the authorization for the services," says Brooks. Patient access staff members often had to call the office repeatedly to confirm that they had done so.
"Then, we would check the various payer sites or call the payers to see if the auth had been issued," says Brooks. Staff members also had to confirm that the authorized service matched the actual service the patient was scheduled to receive. "We would sometimes go down to the wire — the day the patient was scheduled for the service — and still not have the necessary authorization to provide the service," says Brooks.
To maintain good customer relations, the service often was provided without the authorization, which risks a claims denial. With the new process, says Brooks, "we have seen a decrease in the no auth’ denials, an increase in our volumes, and improved customer service."