Patient access departments are improving the “clean claim” metric to decrease claims denials. Some successful approaches:
- Obtain authorizations and referrals before the patient arrives.
- Use registration accuracy and eligibility software to confirm coverage and improve accuracy.
- Review accounts that were denied to see if staff followed the proper procedure.
The “clean claim” metric — the number of claims sent without errors causing denials — is extremely important to the overall revenue cycle, says Nancy Diamantopoulos, director of patient access at Steward Holy Family Hospital in Methuen, MA.
“Patient access is essential in the clean claims process,” she adds.
Steward Holy Family’s patient access department works daily with the hospital’s central business office to ensure claims bill out “clean” and are paid timely.
“These meetings are extremely productive in reviewing our claims errors,” Diamantopoulos says.
The department recently implemented a process to ensure all authorizations and referrals are obtained prior to the patient visit.
“This eliminates the ‘dirty claim’ and denials,” Diamantopoulos notes.
As director of patient accounting at Norfolk, VA-based Sentara Healthcare’s Central Business Office, Brenda Loper struggled for years to find a way to reduce registration errors causing claims denials.
“When I moved to the front end and assumed responsibility for access services, I was determined to find an answer,” says Loper, now director of patient access at four Sentara Healthcare hospitals.
Loper found that nearly all front-end errors stemmed from these two problems:
- inadequate staff education, and
- failing to provide employees with the tools needed to get it right the first time.
“As I told our staff in patient accounting, registration staff do not get up in the morning and say to themselves, ‘I am going to make 16 errors today. That is my goal,’” Loper explains.
The department’s goal is 99.9% accuracy on all registrations.
“Nearly all of our facilities are meeting or exceeding this goal now,” Loper says.
ID Reason for Denial
Sentara Healthcare’s patient accounting department sends a weekly claims denial report to patient access. Every account that was denied on remittances the previous week is listed.
“Specific codes clearly show the reason for the denials,” Loper says. Patient access focuses on these four types of denials:
- The claim was adjusted because the care may be covered by another payer per coordination of benefits;
- Expenses were incurred before the coverage took effect, during a lapse in coverage, or after the patient’s coverage was terminated;
- The claim was denied because the patient cannot be identified as the insured;
- Services were not covered because the patient is enrolled in a hospice.
“The manager of access in each of our facilities reviews the accounts to determine if staff followed the correct procedure,” Loper says.
For instance, an employee might not have launched the eligibility software or may have attached the incorrect insurance to the record.
The manager meets with each employee to review errors and determine why they occurred.
“The first step is to determine if there was a reason beyond their control, such as system downtime preventing the eligibility launch,” Loper says.
Once this is ruled out, the employee and manager discuss the errors made. Together, they figure out what should have happened.
“Once this has been done, if errors continue to occur, they are dealt with based on department policy,” Loper says. (See sidebar below to learn how patient access uses technology to reduce errors.)