Access Management Quarterly

These strategies can pave the way to a clean claim

Prevent unnecessary claims denials

The Medicare Secondary Payer questionnaire is not complete. The Medicare number is missing from a replacement plan. The subscriber name or date of birth is a mismatch. An account has incorrect insurance coded for third-party liability.

These are some of the challenges patient access staff face on a daily basis. At Minneapolis' Hennepin County Medical Center, access staff now use a new electronic health record with enhanced eligibility technology enablers, as well as more robust work queue functionality.

"When we have a claim on the back end that has hit a claim edit, we have multiple work queues that are worked, prior to the claim going out the door," says Michele Young, manager of the hospital's emergency admissions and registration zones.

One particularly difficult challenge involves ambulance billing. "We have a large ambulance service here. For 60% of those ambulance runs, the patient is not transported to our facility, but we do the billing for those ambulance runs," she says.

The hospital's practice improvement team looked at the problem and found that for 50% of these patients, the paramedic was unable to obtain a Social Security number although the patient was over 64 and likely to have Medicare coverage. "So we may find a Medicare supplemental and will code it. Of course, when it goes out to that supplemental payer, they will deny it, saying there is other coverage," says Young. "But without the Social Security number, we cannot check for eligibility with Medicare. Our plan for the future is to utilize a product called Search America, which may return a Social Security number."

Many billing challenges

Karen Condon, acting manager of the hospital's financial clearance center, says that the new electronic health record system has helped the department to identify patients who may require referral or authorization before treatment starts. "We can identify specific payers, and this alerts us to check for a referral," she says.

One challenge involves outpatient visits for radiology. "A few years ago, insurance companies started requiring authorization numbers," says Condon. "With our electronic system, we can easily identify those appointments, but we struggle sometimes if the insurance company asks for a lot of medical information."

Staff often play phone tag, going back and forth between physicians who ordered the treatment plan and the insurance company, trying to get it authorized. Otherwise, services provided could be denied.

Coordination of benefits

Many of the department's current claim denials involve Coordination of Benefits. "There are some system constraints," says Young. "Depending on what the patient's coverage is, there are a couple of things we have a real big challenge with. One of those involves our cost plans. For our facility fees and our paraprofessional fees, we are billing Medicare. But for our professional fees billed out of HFA [Hennepin Faculty Associates], our counterpart, their clinics don't bill Medicare. So we have had to manually intervene for those cost plans." For HFA to bill correctly, the system always puts the health plan as the primary. Hospital staff have to remember to go in and manually change this.

Another billing challenge involves the dental clinic, which is billed by HFA. "Hospital staff have to remember to remove the dental plan as the primary plan from non-dental accounts," says Young.

Another challenge involves untimely filing, which is often related to coding and documentation. It also may be due to lack of authorizations. "We may not have received an authorization number or may not have the correct insurance information," says Condon. The patient may arrive unconscious or may not have his or her information with them. At times, access staff may not have been able to obtain it until after the patient has been discharged or after he or she has been in the hospital for three or four days, but the payer may require notification within 24 hours. This claim may be denied.

"The number of appointments that we schedule without the patient, historically, has been an issue here," says Young. "Other clinics may be calling, or it may be a friend of the patient who doesn't have the information that we need. Of course, our batches checking for eligibility are going out to our biggest payers. If the patient has no insurance, we are only checking Minnesota Medicaid."

Also, an insurance company may change its requirements, such as requiring prior authorization for radiology. "If we don't know about that change, that information doesn't get distributed to everybody in the organization," says Condon.

A state statute requires standard information to be returned from payers, yet several payers still do not return the subscriber date of birth. "Another challenge is that if a payer such as Minnesota Medicaid makes any changes at all in how the display of their response is returned through our eligibility vendor — if they add so much as a semicolon or additional numbers — all of the sudden, our mapping is off," says Young. "And that is how we figured out they made a change. There isn't any requirement for a payer to tell us about the change."

Young says if you don't have the patient in front of you, all of these problems become much more difficult to resolve. For example, hundreds of claims edits involve a patient's name and date of birth failing to match the information from their insurance company.

"That is a huge challenge for us," says Young. "We probably get a minimum of 50 accounts per day every single day of the year. It may be something as simple as a hyphenated name and the payer does not have a hyphen and that creates a mismatch, or the patient tells us her name is Kathleen but the payer lists her as Kathy," she says. "This is a ongoing problem because we cannot change our electronic health records based on what the payer has."

Accurate info is key

Young says the department does whatever it can to ensure that accurate demographic and insurance information is collected.

"We use a third-party vendor for insurance eligibility, so we have access electronically to the majority of our most common payers," she says. "We also have links to additional payers that all the front-end staff have access to. We also have a batch process sending all appointments electronically every night, so that exceptions are caught."

For example, if a patient is coded as having Metropolitan Health Plan but actually has a different plan, this will be caught by staff who work the exception work queues prior to the patient's appointment or admission. For same-day or next-day appointments, there is a look-back batch for those exceptions.

"We have also set up a lot of auto processing within the system," says Young. "If we have a patient on a fee-for-service Medicaid plan, the system will automatically add or terminate coverages based on responses. If a response from a payer in that batch returns that the coverage is terminated, and includes a termination date, then the system will autoterminate that for us."

Likewise, if a coverage change is made, the system will search for any other accounts within that eligibility period that are affected and will place those accounts in a work queue to be corrected.

Errors won't recur

Dorothy Gunlock, admitting and central scheduling manager at Covenant HealthCare in Saginaw, MI, says that implementing an electronic system has helped her to research the "how and why" of registration accuracy issues.

"If someone says, 'This information is missing,' or 'This was entered wrong,' we can run an audit and let them know how it got there. If it wasn't anything we did wrong, I let them know that. And if by chance there is something that I find, I tell them what we will do to prevent it from happening in the future," she says.

If a mistake happens once, the system is tweaked so it does not occur again, by adding a work queue to catch it. For example, if the issue involves missing information, the system is changed so that the staff person can't finish registering a patient without completing that portion.

"A bill won't go out if certain criteria aren't met," says Gunlock. "We tried to build as much of that as possible into the front end, so it won't get to that point."

This ability has contributed to good working relationships. "We hope other departments see we are taking a proactive approach, and that we really don't want to make mistakes," she explains.

Sometimes a complaint involves a misunderstanding, because people are thinking about a previous system when admitting did things differently. "The real picture may be that the information is entered by another area now and isn't something that we would have keyed in. The way information gets there is different now from two years ago," says Gunlock.

"I think people know when they bring something to our attention, if we can do something with our computer system or workflow to prevent future problems, we will," says Gunlock. "That helps departments know that you are not just giving them an excuse or ignoring their concerns."

Checks and balances have helped accuracy so mistakes don't recur. "Now that we are on an electronic system, we can use it to assure that the data are accurate at the point of registration so they flow cleanly through the system," says Gunlock. "Not having multiple data entries from multiple systems really helps to minimize errors."

[For more information, contact: Karen Condon, Manager, Financial Clearance, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415. E-mail:; Dorothy Gunlock, Admitting and Central Scheduling Manager, Covenant HealthCare, Saginaw, MI. Phone: (989) 583-4188. E-mail:; Michele Young, Manager, Emergency Admissions/Registration Zones, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415. Phone: (612) 873-8571. E-mail:]