Put a stop to common, costly claims denials

Many involve communication breakdowns

Keeping up with all the new payer requirements "is getting overwhelming," reports Margie Mukite, director of patient access at Advocate Condell Medical Center in Libertyville, IL. Here are some trends the department is seeing:

• Denials due to incorrect coding.

Registrars might provide the correct code to the payer, but the payer mistakenly puts through a different one, says Mukite. Registrars take extra care to specify the procedure codes, but they also document the time of the call and the individual's name in case the claim is later denied, she says.

"We use that supportive documentation, as to the type of procedure, to overturn those denials," says Mukite. "With proper documentation on the account, we have overturned pretty much all of them."

• Denials based on the patient's status.

Payers often deny claims for admitted patients who initially were called in as outpatient or same-day admits, and vice versa, says Mukite. "When we convert the patient to inpatient status, we have the verifiers notify the payer of the admission," she says. "That has to occur within the timeframe of the patient's stay in the hospital."

Whenever a patient's status is changed, verification staff members are alerted electronically so they can notify the correct payer, Mukite reports.

• Denials based on additional procedures received by the patient.

An authorization might be obtained for a CT of the abdomen, but during the procedure, the provider decides to add a CT of the pelvis. "If there is no communication with the payer, we are not going to get paid for that," Mukite says.

Mukite and other patient access leaders review specific denied claims with unit managers of clinical areas. "This has been successful, because the technicians actually get to see the dollar amount of the lost revenue," she says. "They then have to come up with a strategic plan for how they are going to improve the process."

• Denials due to the payer's claim that a procedure should have done on an outpatient basis.

These denials are happening even when the patient clearly met the hospital's criteria for inpatient status, says Mukite, "but the payer is saying that it doesn't meet their criteria. We reach out to our physicians to help us overturn the denial."

Even if providers give additional clinical information, though, Mukite has seen many claims unsuccessfully appealed due to lack of documentation. "The challenge is that we have to refer to what is documented in the chart," she says. "Since the patient is already discharged, there is not really much we can do."

If the patient's chart indicates he or she met criteria for observation or outpatient status, that documentation stands even if the decision was made later to admit the patient, says Mukite. "We can't go back and change the order to say the patient is being admitted," she says. "We have to catch that before the patient is discharged, so we can properly obtain authorization."

Case management now make an extra effort to identify discrepancies regarding the patient's status, such as a patient classified as an outpatient, but the order states that the patient will be admitted within 24 hours, says Mukite. "They alert us to make the changes, and it goes into the verifier's queue," she says.

• Denials for patients who come in as self-pay, who have insurance that is later uncovered by financial advocates.

"This was an area of broken-down communication," says Mukite. "The information was being added to the system, but it wasn't getting to the next step."

The verifiers are now alerted so they can contact the payer to notify them of the patient's admission when the patient is still in the hospital, she explains.

• Denials involving a miscoding of payers.

About 20% of denials are due to this problem, says Mukite, who adds that patients often present Medicare cards without revealing that they have additional insurance.

"Every facility I know has issues with this. The associates have to be very sharp," she says. "Patients don't understand this and require a lot of education to explain how this works."

Because payers are administered by different companies, registrars might mistakenly select the incorrect payer instead of the main carrier, adds Mukite.

"If the registrar incorrectly codes a patient as Medicare, and a month later it's denied because the patient actually had an HMO, now you have to go through the whole appeals process," Mukite says. "It's going to get denied, because you didn't call it in on time."


Margie Mukite, Director of Patient Access, Advocate Condell Medical Center, Libertyville, IL. Phone: (847) 990-6070. E-mail: margie.mukite@advocatehealth.com.