Regain lost revenue due to claim of no auth

Correct inaccurate information

Claims denials at The University of Tennessee Medical Center in Knoxville have increased 20% to 30%, particularly from major payers including The Blue Cross and Blue Shield Association, United Healthcare, and Humana, according to Stephen Hovan, executive director of patient fiscal services.

Many claims are denied based on inaccurate information, such as the payer claiming that an out-of-network authorization or referral is required when the patient is in-network, or a payer denying an emergency department claim because no authorization was obtained, when one isn't actually required, says Hovan.

"In-network physicians are being excluded by the payer for authorization, and the service is being denied because no authorization was obtained," he adds. In some cases, an authorization is obtained and verified as correct in the payer system or over the phone, and the claim is later denied for an incorrect authorization, says Hovan.

Hovan estimates that 2% to 5% of net service revenue is "protected and regained" with good processes, such as thorough documentation that substantiates the need for all charges in the hospital and physician records.

Patient access staff members record all calls with payers, which are indexed at the account and medical record levels. "When the payer denies the claim, we provide the payer with the recorded message or the transcript," says Hovan. "Ninety percent of the time, they reverse the denial and pay."

Even with the recorded evidence, some payers still will request that the denial go through the appeals process. "This whole process is convoluted. It adds additional expense to the healthcare system, along with adding to accounts receivable days — sometimes up to 60 additional days," says Hovan.

If calls weren't recorded, however, Hovan says the department would have a difficult time in getting denials reversed. "Appeals would be required on all cases," he explains. "Our success rate would drop from 90% to approximately less than 50%."