“You never sent it.” This response was all too common from payer representatives regarding clinical information that had been sent by registrars at Lawrence (MA) General Hospital.

“Frequently, we have to send clinical documentation to support the admission, whether for observation or inpatient status,” explains Gregory Kanetis, MPA, director of patient financial services.

At times, registrars fax required clinical information to payers, only to have the claims denied for failure to provide it. “When payers have their own staffing and processing issues, things fall through the cracks,” says Kanetis. “We were continually following up with phone calls to the payer.”

At University of Utah Health Care in Salt Lake City, payers sometimes falsely claim they failed to receive the clinical information within the required timeframe. “We have found the issue usually lies with the payer not integrating what we send with the claim in their system,” says John Madison, supervisor of revenue integrity in the division of Revenue Cycle Support Services.

In this situation, patient access responds by telling the payer representative, “It must be there.” “Sometimes it gets the representative to utilize other resources, and they find it,” says Madison. “For larger dollar claims, we often use certified mail.”

Recently, the department started recording phone calls that the authorization team makes to the payer when checking authorization requirements and obtaining authorizations. “We have had a lot of success with that,” says Madison.

The recordings become important when patient access is told authorization is not required, but payment is later denied because authorization was required by their policies. In such cases, says Madison, “the authorization representative at the payer was incorrect, and we are able to prove what we were told using the call recording.”

The calls are stored by the employee making the call, with the time, date, and number called documented in the notes, so that managers later can retrieve and listen to the call if necessary.

Registrars at Lawrence General Hospital often struggled to prove they had sent the clinical record. “We had to backtrack, and it was difficult for us to ascertain if and when we actually sent it,” says Kanetis. “Maybe we had the fax confirmation, and maybe we didn’t.”

Even with the fax confirmation sheet, patient access couldn’t prove the payer actually received the information. This problem resulted in many claims being denied, which necessitated a lengthy appeals process. Even if denials were successfully appealed, says Kanetis, “it takes an additional 30 days and pushes the A/R [accounts receivable] days out.”

No more questions

To reduce claims denials, patient access leaders at Lawrence General “are being aggressive and proactive to get the necessary authorizations in place pre-discharge,” says Kanetis.

The department recently implemented a web-based care management tool (Morrisey Concurrent Care Manager, manufactured by Seattle-based MCG). “This streamlines the communication between case management and the admitting benefits counseling staff who manage the authorization piece of it,” says Kanetis.

Any clinical records requested by payers now are sent through the automated tool, which logs the exact date and time the information was sent. “There is no question who sent it and when,” he says.

Payers’ insistence that the clinical record wasn’t received created finger-pointing between case management and financial services.

“Each said, ‘You didn’t send it’ or ‘You should have notified me more timely,’” Kanetis says. “But it wasn’t that we had a bad process. The problems were actually more payer-related.”

With good documentation tools, case management and financial services take a collaborative approach if payers don’t give the authorization timely. “We are getting the response, ‘We didn’t receive the records’ less often. But that doesn’t make the payer respond any quicker,” says Kanetis.

Staff are armed with excellent documentation when they call to follow up with payers. “We are seeing fewer ‘no authorization’ denials,” reports Kanetis.

Conflicting information

Conversations about whether an authorization is needed sometimes become debates over “he said/she said.”

“We are always battling whether services are medically necessary,” says Kanetis.

At times, various payer representatives give different information about what’s required for a particular case.

To address this issue, the department is looking into implementing telephone recording software. “This would take the ambiguity out of these conversations,” says Kanetis. (See story on how a patient access department achieved a very low denial rate despite increased payer requirements, below, and see ample scripting used to inform patients of out-of-pocket costs.)

SOURCES

  • regory Kanetis, MPA, Director, Patient Financial Services, Lawrence (MA) General Hospital. Phone: (978) 683-4000 ext. 2916. Email: Gregory.Kanetis@lawrencegeneral.org.
  • John Madiso, Supervisor of Revenue Integrity, Revenue Cycle Support Services, University of Utah Health Care, Salt Lake City. Phone: (801) 587-6357. Email:John.Madison@hsc.utah.edu .