Patient access departments are dealing with many COVID-19-related reimbursement issues. San Diego-based Sharp HealthCare sees some self-insured plans assign coinsurance to the COVID-19 prescreen for surgeries. “We have opted to adjust the bill if any coinsurance is applied for this lab test,” says Laurel C. Achenbach, manager of patient financial services.
Telehealth necessitated certain changes in many payer contracts at Intermountain Healthcare in Salt Lake City. “We had thousands of telehealth claims that had been previously submitted. These needed to be reprocessed based on finalized payer contracts,” says Jeff Howes, assistant vice president of the revenue cycle.
The payer contracts lacked specifics on payment rates, which services were covered, and what billing codes and modifiers had to be used. “Payers had different coding requirements that changed frequently,” Howes notes.
A few COVID-19-related denials are trickling in. Overall, though, the proactive changes to payer contracts paid off. “Most denials now seem to be related to payer system issues. These are easily remediated with a call to the payer,” Howes reports.
Health plans issued all kinds of waivers during COVID-19 — for authorizations, for copays, and for telehealth. But patient access departments soon found the devil was in the details, with varying time frames and stipulations all coming into play. The result: A flood of denied claims.
“It’s an interesting time for the revenue cycle, given where we are with COVID-19. The landscape is certainly different,” says Geoff New, vice president of provider solutions, revenue cycle of Ciox. Here are some issues:
• Surge of denied claims. “We are starting to see a lot of denials come back as it relates to COVID-19,” New says.
Most of the time, the problem is missing or incorrect information. “It’s our job as revenue cycle folks to tell the story of what happened with that patient while they were in our care. If we tell that accurately and completely, we will get every dollar that’s rightfully coming to us,” New argues.
Typically, the patient goes home, the claim goes out missing a key piece of documentation, and the denial happens months later. “There’s all these opportunities that we miss,” New says. “Right out of the gate, we’ve got to say, ‘Stop the train, we’ve got to get this information.’ Otherwise, we’ll get the denial.”
• Many COVID-19-related denials are never even appealed, just because of lack of resources. “In 2021, we don’t have the time or the dollars that we would have had a year or so ago to go back and do the rework,” New says.
• Inpatients end up with denied claims because no one documented their positive COVID-19 status during admission. “Staff should document concurrently throughout the patient’s stay. If we don’t document concurrently, we’re losing before we get out of the gate,” New explains.
Without concurrent documentation of a positive COVID-19 result, it appears the admission had nothing to do with COVID-19. “Payors will say it was just an exacerbation of bronchitis or emphysema,” New says. “We’re got to have that extra documentation more than ever to keep those payers on track.”
If they do not have it, hospitals lose reimbursement. Good, early communication between the clinical side and the revenue cycle side is crucial. “Previously, the clinical path and the financial paths never crossed. The ‘clinically integrated revenue cycle’ has taken hold,” New observes.
In this model, case management and utilization review play a bigger role in patient access processes. Some hospitals have implemented a validation process in the clinical documentation improvement and/or coding areas. The medical record is reviewed while the patient still is in house to identify the presence of a COVID-19 test. “Patient access needs to switch the mindset to prevention as opposed to ‘We’ll take care of it later,’” New says.