More payers require info on clinical review

Denials are the result

Payers are frequently requiring additional clinical information from the provider or medical staff as to the medical necessity for a procedure or surgery, says Nan Olivieri, a supervisor at the Financial Clearance Center at Hennepin County Medical Center in Minneapolis.

Clinical staff might not always be familiar with insurance terminology, due to the use of different terminology such as notifications versus authorizations, she explains. "Clinical staff do not always have administrative time and are not always prepared to respond to some of the insurance inquiries," says Olivieri, adding that financial clearance staff diligently work to complete all inpatient notifications and authorizations within the pre-established timeframes required by different insurance companies.

The best strategy is to have a centralized clearing center for all inpatient authorizations and notifications, with staff fully trained to administer and document pertinent information in a timely manner, says Olivieri.

To avoid future denials, the denial team reports back to departments when trends are identified specific to that area, such as a lack of authorization, says Lori Nix, the hospital's claims manager of revenue cycle management. "Once they're aware of denials, most clinical areas are very interested in what they can do going forward to prevent these denials from occurring," she says.

For example, technicians were informed about authorization denials related to radiology services. "We do this not to point out errors, but to educate them on what the payers are actually looking for in order to pay the claim," says Nix.

Sources

• Lori Nix, Manager, Claims Revenue Cycle Management, Hennepin County Medical Center, Minneapolis. Phone: (612) 873-6078. Fax: (612) 630-8294. E-mail: Lorraine.Nix@hcmed.org.

• Brian A. Todd, CHAM, Manager, Patient Access Staff Development and Training, Lourdes Health System, Camden, NJ. Phone: (856) 824-3125. E-mail: toddb@lourdesnet.org.