Despite increasing requirements from payers, the denial rate at Dublin-based Ohio Health is holding steady at just 0.10%.
“This is a superb number,” says Pam Carlisle, senior director of patient access services, who says it helped them win the MAP (measure, apply, perform) Award for High Performance in Revenue Cycle from the Healthcare Financial Management Association (HFMA) again. HFMA’s MAP keys are performance indicators used to measure revenue cycle processes, financial performance, and patient satisfaction.
Payers are requiring more documentation on reasons for services and supporting materials to show that all other options have been considered. “‘Conservative’ treatment is a big term coming up with some payers,” says Carlisle. This term means that before a patient has a radiology study such as an MRI, patient access needs to show that less costly alternatives were tried, such as therapy, braces, or medication. Only then is the test precertified and paid for.
“It is taking twice as long to get a precertification prior to a procedure, due the increases in clinical documentation,” says Carlisle. “As precertification requirements grow, the FTEs needed also grows to handle the volume.”
While some plans allow online requests, many plans still require a telephone call.
“The growing payer demands do increase the labor costs for organizations related to securing payment for services,” says Carlisle. The department uses these approaches to reduce claims denials:
Physicians are educated at staff meetings, with lunch provided, on the specifics of what documentation is needed.
“We need to be sure we are capturing all the data,” says Carlisle. “Reeducation on payer requirements is a must, as they change so quickly.”
The process of meeting payer requirements is automated.
Questions are put in place to secure specific documentation, such as “Upper or lower quadrant?” “Right or left leg?” or “What specific regions?”
“Asking these clarifying questions can help the documentation be stronger and support the reason for the test,” says Carlisle.
Cross-functional teams meet to review denials related to failure to meet payer requirements.
The team gets to the root cause of the issue and implements a solution for future cases. “Depending on the size of your organization, you could be risking millions should you not mitigate denials,” warns Carlisle.
Patient access leaders at Huntsman Cancer Hospital in Salt Lake City, UT, review monthly and quarterly reports on “controllable” writeoffs. These are writeoffs completed on accounts with denials due to lack of appropriate authorization or certification, non-covered services, and non-medical necessity services.
“More requirements for pre-authorization creates more work for the ordering physicians. There are forms to be filled out and signed, peer-to-peer reviews, and appeal letters,” says patient access supervisor Junko I. Fowles, CHAA.
All of these requirements cause delays in obtaining authorizations. “We have an effective workflow in place to identify services that require prior authorization, and for these accounts to be worked by prior authorization staff, timely,” reports Fowles.
Here are two challenges the department is seeing:
Some insurance plans won’t allow retro authorization if urgent add-ons are performed, such as CT scans of the abdomen or pelvis ordered for cancer patients.
“This most likely will end up in provider writeoffs, since no appeal is available for such denials,” says Fowles. It is difficult to identify non-covered services and/or non-medically necessary services prior to admission.
“The procedure codes we verify do not require prior authorization and/or covered services per payer guidelines,” says Fowles. However, the patients’ diagnoses don’t always meet the criteria. Often, patient access staff members don’t find this out until the claim is denied.
“The solution to this will possibly be creating an edit to identify CPT/diagnosis code combinations for possible denials due to non-covered services,” says Fowles.
Pam Carlisle, Senior Director, Patient Access Services, Ohio Health, Dublin. Phone: (614) 544-6099. Email: [email protected].
