EXECUTIVE SUMMARY

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.)

SOURCES

  • Nancy Diamantopoulos, Director, Patient Access, Holy Family Hospital, Methuen, MA. Phone: (978) 687-0156, ext. 2426. Email: nancy.diamantopoulos@steward.org.
  • Brenda Loper, Director, Patient Access, Sentara Healthcare, Norfolk, VA. Email: bcloper@sentara.com.

Evolving Regs Demand Right Technology

As soon as registrars get comfortable with a certain payer or regulatory requirement, they can count on it to change.

“Or new ones will be created,” Brenda Loper says. “The key to thriving in this world of change is having the right technology.” The patient access department recently implemented these solutions:

  • Supervisors use registration accuracy software to give feedback to staff while they are completing a registration.

“We have compared it to having a supervisor standing behind each employee and gently tapping them on the shoulder when they make a mistake,” Loper says, adding that registrars and managers receive daily feedback on uncorrected errors. “A very practical benefit of this product is our ability to create new rules whenever we need them.”

When the department learns of a change in payer requirements, Loper says, “we contact our internal support person and discuss the change needed.”

She looks at what the system can support, and then builds rules to detect errors. For instance, the hospital is contracted with two of the three carriers in the state who offer Coordinated Care Plans, a combination of Medicare and Medicaid coverage. The uncontracted carrier will only pay for emergency services.

“A rule was created to fire off an error message based on the insurance plan code created for this carrier,” Loper says.

Another rule was set up to flag any account that is set up with Medicare Part B as the primary financial class. This should be used only if the patient does not have Part A benefits.

“In that rare occasion where Part B is correct, the error is disputed with an explanation,” Loper adds.

  • Registrars use eligibility software to confirm patients’ coverage.

Scheduled patients are handled by a centralized pre-registration department. “So that has never been an issue,” Loper says. “Walk-in patients present the greatest challenge for ensuring they have coverage for services.”

This is true for both the ED and outpatient services. For these patients, the department relies heavily on eligibility confirmation software to be sure the information provided at the time of service is accurate. This also gives patient access the chance to collect copays.

“We recently changed the eligibility vendor we were using. One immediate result was the elimination of employees ‘forgetting’ to launch a query,” Loper says.

The new software does it automatically, and it can’t be bypassed. It hasn’t been operational long enough to produce meaningful reports on claims denials yet, but Loper is very optimistic.

“I’m excited to see how the reports coming from patient accounting will be impacted by this change,” she says.