Registrars, departments partner on denials

Avoid costly mismatches

Claims denials often occurred at Valley Health System in Ridgewood, NJ, because the patient's disposition didn't match up with what the Centers for Medicare & Medicaid Services (CMS) required to authorize a procedure, reports Maura Corvino, MSOL, RN, CEN, assistant vice president for emergency services and patient access.

"The physician knew what he wanted to do, but he wasn't writing it in the language that was required for the correct type of admission," she says. These changes were made:

• Patient access staff gave community physician offices a list of the information needed for scheduled patients.

"The office manager provides us with what we need to schedule and speak to the patient, and move forward with the process," says Susan Sigler, supervisor of Valley Health System's patient access center. "We set it up in a way that we think flows nicely for the patient."

• A physician champion visited provider offices to go through an online learning module with physicians.

"This made the communication easier, and the buy-in by the physicians a bit better and faster," says Corvino.

Physicians were instructed to use the CMS inpatient list to validate their intent, says Corvino. "We then verify that what they want equals what CMS allows for that procedure," she says.

The physicians were asked to provide certain data points when requesting a procedures or an admission, explains Corvino. "This facilitates patient access staff in obtaining the necessary certifications and authorizations prior to case day or admission," she says.

• When patients undergo surgery, every step in the process is now time-stamped on an electronic dashboard.

This change means that office staff can keep track of where the physician is at all times, says Sigler. "Previously they were always trying to track their physician down. Were they in the OR, the PACU, or in a patient room? So this turned out to be an unexpected benefit for them," she says. "It is a nice perk that has helped engage them in using the system."

This change also means that all of the areas involved in the patient's care can see what is happening, says Sigler. Transport can see when they need to move patients, PACU can see the planned departure time from the OR, and the inpatient units can see when the patient is scheduled to leave the PACU, she explains. "Everybody has that transparency to know what is coming, without needing to scratch their head and wonder when the patients are coming to them," says Sigler. "It allows for the pre-planning of staff and work activities."

Sources

For more information on working with other departments on claims denials, contact:

  • Maura Corvino, MSOL, RN, CEN, Valley Health System, Ridgewood, NJ. Phone: (201) 447-8301. Fax: (201) 251-3467. E-mail: mcorvin@valleyhealth.com.
  • Susan Sigler, Valley Health System, Ridgewood, NJ. Phone: (201) 447-8000 Ext. 2778. Fax: (201) 251-3467. E-mail: ssigler@valleyhealth.com.