EXECUTIVE SUMMARY

Patient access departments are using contractual language to overturn unfairly denied claims. Take the following steps to challenge payer requirements:

  • Ask the hospital’s contracting department for education on payer contracts.
  • Find out if requirements conflict with what is stated in the contract.
  • Include contractual language in appeal letters.

A claim is denied because the payer was not notified of the patient’s admission within 24 hours. At first, it seems pretty clear that the claim won’t be paid, since the required timeframe was not met.

“However, there have been times when we look at our contracts, and we find out that we actually have a 48-hour window to notify the payer of the admission,” says Suzanne Droste, MBA, director of access services at UW Health in Madison, WI.

Armed with this knowledge, patient access has appealed many denied claims successfully. “Before, we may have written off these charges, assuming we missed the notification deadline,” says Droste. “We have realized that insurance company customer service reps generally quote their standard contract language.”

The hospital’s specific contract with the payer is sometimes different. “Knowing the requirements specific to our contracts has been key,” says Droste. “This has given us more knowledge and ‘ammo’ when appealing denied claims.”

Recently, patient access leaders met with the contracting department to get this information. “The first takeaway from this collaboration has been a handful of plain language contract summaries from our top payers,” says Droste. Specific wording from contracts about notification requirements has proven to be very valuable for patient access.

“We can tell them what our contract says, and feel confident in our appeals,” says Droste. “We are much more successful.” (See related story on the patient access department’s denials management team.)

Nurses Stay on Top of Auth-related Denials

Constantly changing payer requirements are a top pain point for patient access departments.

“It is difficult to stay on top of all the notification deadlines, prior auth requirements, and timeframes to appeal denials,” says Suzanne Droste, MBA, director of access services at UW Health in Madison, WI.

UW Health recently created a small denial management team within the prior authorization department. “We are in the early stages of building this team,” says Droste. “We are continually finding ways to improve and expand.”

This team currently consists of two nurses who handle prior authorization-related denials. “These are not new FTEs. We have slowly built this team from existing resources,” Droste explains. Previously, both of the nurses worked as pre-certification nurses.

The group also handles denials related to patient classification. For instance, the hospital may bill as inpatient status, but the payer says only observation status is appropriate. “The nurses research the case, appeal the denial if appropriate, and keep tabs on the final outcome,” says Droste.

Most of these cases take a long time to review. “It requires digging into the chart for clinical information to support inpatient classification that we have not yet provided to the payer,” Droste explains.

The denial management nurses spend a lot of time gathering information to include in detailed appeal letters.

“We are most successful when we can tell the entire story, using clinical information to back it up,” says Droste.

Time Spent Is ‘Enormous’

“No authorization” is a top reason for denied claims at The Ohio State University Wexner Medical Center. “It currently represents about 22% of our denial challenges that result in lost net revenue,” reports Jennifer Lanter, MSPH, BSN, RN, CCRC, director of revenue cycle clinical support.

Payers currently set their own response timelines. Some take up to 30 days to respond to an authorization request. 

“We spend an enormous amount of time following up on requests to determine the status,” says Lanter.

Typically, payers don’t respond until the end of their timeframe. Sometimes, patients must be rescheduled only because a payer has not responded to the requests for authorization in time.

“We push back all of the time by frequently calling to indicate when we need a response,” says Lanter.

Payers don’t always meet their timeframes. In these cases, says Lanter, “we escalate through our managed care department, if we are contracted with the payer.”

Retro Auths Disallowed

Getting authorizations for “stat” or same-day requests is particularly challenging for patient access. “We spend time trying to secure the authorization before the services are rendered. But taking care of our patients is our highest priority,” says Lanter.

The hospital provides urgent services regardless of the authorization status.

“We attempt to capture these through a work queue in order to obtain retro authorization,” says Lanter.

To successfully appeal denied claims, good documentation of medical necessity is needed. Often, however, the payer is not disputing that the patient needed the service — only the fact that the authorization was not in place before the service was provided.

“We are frequently frustrated,” says Lanter. “The services are medically necessary, but are denied because of no authorization.”

Requirements Unmet

Payers continuously change their authorization requirements throughout the year. The verification process varies, too.

“Payers have a multitude of ways to verify authorization requirements,” explains Lanter. For some, entering a CPT code on the payer website is sufficient. Other payers require a time-consuming phone call.

Requirements differ based on the level of service — inpatient, outpatient, or observation. “Or they may have medical policies that state a service is only covered when certain conditions are met,” says Lanter. Payer representatives do not always include this information during calls.

To stay on top of things, patient access must review each payer’s website continuously for new authorization requirements. Anytime there is a new requirement, process changes are necessary.

“As you can imagine, requirements may slip through the cracks,” says Lanter. Recently, “no auth” denials have been occurring for devices. “Historically, an authorization for a procedure covered the device used in the procedure,” says Lanter.

For instance, authorizations for a cochlear implant covered both the procedure and the device. Payers now require separate authorizations for both the procedure and the device. 

“This has required us to develop a completely new workflow to include the device codes in the authorization process,” says Lanter.

Issues like this are identified when patient access reviews monthly data to identify the root causes of denied claims. “We reach out to the departments performing the services to fix operational processes,” says Lanter. “We make changes to our system workflows when new services require authorization.”

Patient access updates tip sheets and educates ordering physicians on additional documentation that is needed. “We are also looking at additional tools to assist with managing the continually changing payer authorization requirements,” says Lanter.

SOURCES

  • Suzanne Droste, MBA, Director, Access Services, UW Health, Madison, WI. Phone: (608) 263-6915. Email: sdroste@uwhealth.org.
  • Jennifer Lanter, MSPH, BSN, RN, CCRC, Director, Revenue Cycle Clinical Support, The Ohio State University Wexner Medical Center, Columbus. Phone: (614) 293-2115. Email: jennifer.lanter@osumc.edu.