Admission notification denials are no longer happening at Moffitt Cancer Center in Tampa, FL, thanks to collaboration between patient access and case managers. “We are not experiencing denials due to this issue. We have a robust submission and follow-up process,” reports Viviana Beland, director of the financial clearance unit.
For urgent admissions, payors allow notification on the next business day. For planned admissions, authorization must be secured before admission. “We use worklists that are created for inpatient encounters only. It allows the team to easily identify the inpatients, and keep those separate from outpatients,” Beland says. It also prioritizes the workload. “Every single patient in the worklists is worked before the end of the day,” Beland adds.
Sometimes, there is just no time to wait. For urgent surgical cases, care proceeds with the authorization in “pending” status. The health plan is determining the status (outpatient or inpatient). “We proceed with the surgery as outpatient status,” Beland says.
Once the surgery is finalized and the patient meets inpatient status, case managers become involved. They contact the health plan’s utilization review department to justify the need to admit.
“They have a clinical discussion with insurance company after surgery, but before the admission,” Beland says. “Since admission meets medical necessity, we get an approval.”
At Children’s Hospital Colorado in Aurora, patient access has been successful proving medical necessity with the help of case managers.
“Over the past year, we have done a ton of work around defining role clarity,” says Suanne Kindel, operations manager of patient access and financial counseling.
Each revenue cycle area plays a different role in financially securing every inpatient visit. “We mapped out each direct admit process. It became clear that the inpatient workflow is very complicated, like a big maze,” Kindel reports.
Previously, the department’s weekly meetings focused on high-dollar accounts. Now, they cover scheduled admissions and other inpatient cases. “We can now be proactive with case management,” Kindel says.
This helps when a patient comes through the ED, and registrars cannot obtain insurance information at arrival. “This can cause delays in notification and sending clinicals,” Kindel notes.
It has become clear that a strong working relationship among case management, patient access, insurance verification, billing, and financial counseling is critical. “We now have the ability to be proactive when an insurance will not cover an inpatient stay,” Kindel adds.