EXECUTIVE SUMMARY

Claims denials often occur as a result of “mismatches” between what was ordered or scheduled, and what actually was done. The following steps will help ensure payment:

  • Schedule tests only if the authorization is in place.
  • Confirm that correct codes are in place before authorization is requested.
  • Include multiple codes in orders if possible.

Once a physician puts in orders for a patient, patient access jumps into action. Registrars do everything possible to secure authorizations and ensure payment for the provider and the hospital.

But what if the Healthcare Common Procedure Coding System (HCPCS) or CPT (Current Procedural Terminology) codes are incorrect?

“I don’t think physicians fully understand when they order these tests how manual hospitals are in making sure that the test done matches the authorization,” says Suzanne Lestina, CPC, FHFMA, vice president of revenue cycle innovation in the San Diego office of Avadyne Health, a provider of revenue cycle management services.

For example, the physician schedules a CT of the brain with contrast, and registration gets the authorization. The order goes through to radiology, but no one notices that the physician added an MRI or other test.

“Nobody says, ‘The authorization doesn’t match,’ until the pieces are put together on the billing side,” says Lestina.

A surprising number of claims denials happen because of this very common scenario. “It’s a whole process breakdown,” says Lestina. “Hospitals really need to engage key stakeholders in understanding this.”

The resulting lost revenue can be devastating to the many hospitals that are struggling financially. “Many of the clients I deal with are on hiring freezes,” notes Lestina. “Why do we have a process that results in lost revenue?”

Different Test Done

A patient needs a CT of the brain without contrast, and the test is scheduled. Patient access obtains an authorization for that test. However, when the physician writes up the actual order, he orders a CT of the brain with contrast. “So the test that’s ordered differs from the CPT code of the test that’s called in. And nobody sees that it’s incorrect,” says Lestina.

Registration typically doesn’t have access to the patient’s medical records to view the actual order. Radiology has no way to see that the order they receive is different from what was authorized.

“The doctor is treating patients, and is not thinking along those lines,” says Lestina. “Nobody stops to think, ‘This is different.’ There are lots of opportunities for this to fall through the cracks, and it happens all the time.”

Requests for tests can come from both the physician’s office and the patient. “In both cases, the test is scheduled even if an actual order wasn’t received yet,” says Lestina. Patients are asked to bring the order with them, but registrars rely on the patient’s interpretation of what test is needed. In other cases, registrars take verbal orders from the office staff, and ask to have the order sent over.

“If it’s not matched with the test that was just scheduled, and it’s not compared, then registration staff are following up on an authorization that is potentially for the wrong service,” says Lestina.

A ‘Huge Dissatisfier’

If patients show up for a test without an authorization in place, hospitals generally allow them to have the test done anyway.

“Hospitals balk at turning the patient away. They want to get the patient through, and then get the authorization,” says Lestina. “People have to understand the ramifications of this.”

The obvious problem is that payers can and do refuse to pay if the authorization wasn’t obtained prior to service.

“It doesn’t do anybody any good if the patient has the test, but the hospital has to write it off or the patient has to pay for it,” says Lestina. “That’s a huge dissatisfier.”

To ensure payment, tests would be scheduled only if the authorization is in place and the CPT or HCPCS code matches. When the physician’s office calls to schedule a patient for an MRI, registration should ask for the authorization number. “If there is none, the response should be, ‘Call me back, and we’ll schedule it the minute you do,’” says Lestina.

If a test is done with contrast, but the authorization is for a test without contrast, “the patient is caught in the middle of the broken process,” says Lestina.

Ideally, radiology would immediately notify patient access if a different test is done. “But I don’t know anybody who’s actually doing that,” says Lestina. “It’s a huge cultural thing. It’s bringing the clinical and financial sides together.”

$6 Million in Write-offs

Lestina often discusses the issue of mismatched authorizations with her hospital clients, but it is hard to overcome. “Often, hospital administrators or clinical areas don’t see the process as part of the patient’s experience,” she explains.

Even at hospitals with entire departments dedicated to obtaining authorizations, mismatches between what was ordered and what was authorized are not caught. At one hospital, authorization write-offs totaled $6 million in one year. Lestina identified these two problems that were contributing to the write-offs:

  • Frequently, patients were not rescheduled, even if the authorization was not in place.
  • Patient access relied on the physician to conduct the peer-to-peer review if required by the payer. There was no follow-up to ensure the authorization actually was secured.

“Employee physicians are easier to get on board,” says Lestina. “Physicians in the community are harder to engage.”

By collaborating with radiology, patient access can close “information gaps,” says Lestina. “Walk through what currently happens — a day in the life of an authorization — and identify where all the gaps could appear.” (See related story on how patient access can fix “mismatches.”)

Catch ‘Mismatches’ Before Denial Is Triggered

Patient access leaders at Moffitt Cancer Center in Tampa, FL, created a worklist to capture “mismatches” in authorizations that were causing claims denials.

“Our system identifies all the high-tech radiology tests that have already been financially cleared, but the order has changed. These encounters are routed to a unique list,” says Viviana Mahon, manager of the financial clearance unit.

A team member from the financial clearance unit identifies if the new test is covered under the current authorization number. If it’s not, the insurance company is contacted for an updated authorization.

“This worklist is worked in full no later than the date of service,” says Mahon.

As a result of this new process, the hospital no longer sees denials on surgical cases due to discrepancies between the authorized procedure and the performed procedure. Mahon estimates that denials have decreased by 24% overall, in part because of the new protocol.

Once the physicians order a surgical case, the coder in the financial clearance unit reviews the order and assigns the proper codes before authorization is requested. “This avoids denials in the back end,” says Mahon.

At Salt Lake City, UT-based Huntsman Cancer Institute, the patient access department set up a workflow just for stat or same-day add-on orders. “The preauthorization team can initiate the auth process right away — although some plans won’t grant approval timely,” says Junko I. Fowles, CHAM, supervisor of patient access and financial counseling.

When that happens, financial counselors and ordering providers get involved for urgent peer-to-peer reviews. If necessary, they give patients the option of paying out of pocket for the test. “The appropriate procedure may not be determined until the patient actually goes into the OR, or until same-day lab tests are run, in the case of chemotherapy,” says Fowles. Sometimes surgeons put in the order in the form of “CPT XXXXX vs. XXXXX”  

Fowles explains, “The pre-auth team is able to submit both codes to the insurance medical review team, when the actual procedure being performed could be ‘either/or.’”

SOURCES

  • Junko I. Fowles, CHAM, Division of Revenue Cycle Support Services, Huntsman Cancer Hospital, Salt Lake City, UT. Phone: (801) 587-4036. Fax: (801) 587-8269. Email: Junko.fowles@hsc.utah.edu.
  • Viviana Mahon, Manager, Financial Clearance Unit, Moffitt Cancer Center, Tampa, FL. Phone: (813) 745-1937. Fax: (813) 449-8869. Email: viviana.mahon@moffitt.org.

SOURCE

  • Suzanne Lestina, CPC, FHFMA, Vice President, Revenue Cycle Innovation, Avadyne Health, San Diego. Phone: (619) 819-8844 ext. 1053. Email: slestina@avadynehealth.com.