Get contact info right the first time to avoid denials

An incorrect address sounds like a very simple matter to correct, but this wrong information can lead to payment for a valid insurance claim being delayed or denied altogether. This is something that no patient access department wants.

University of Pittsburgh Medical Center (UPMC)'s patient access department has made collecting accurate information a priority, including implementing online address confirmation and eligibility tools. With about 4.5 million outpatient visits a year, the department manages about 50,000 mail returns from the post office annually.

"We take pride in our ability to keep our patient information as updated as possible. But even a very small percentage of error can require manpower and re-work that can negatively impact clinical care, as well as timely access to and reimbursement for services," says Karen Shaffer-Platt, executive director of access/information services.

Customer service is an issue

It's important for access departments to make patients feel "recognized," wherever and whenever they seek services in the health system, and this includes having the correct demographic information.

Regarding scheduled outpatient care, Shaffer-Platt says that it's access' responsibility to ensure that the day of service focuses on the clinical care the patient is receiving. "We do everything possible to verify and re-confirm, through any means possible, that the information that we have on file for the patient is current, meaningful, and reflects accurate information prior to the date of service," says Shaffer-Platt.

Accurate contact information helps with compliance with the Health Insurance Portability and Accountability Act (HIPAA), since violations are possible if information is sent to an incorrect address or phone number. Inaccurate information "also leads to overall dissatisfaction in our patient population," says Diane Zilko, senior director of the physician services division access development/central call centers. "They may feel that we don't care enough to find out where they are, or to ensure that we do everything correctly."

Real-time verification

Ensuring a patient's contact information is correct in "real time" improves billing and statement delivery, thus increasing your cash flow, says Ron Camejo, director of revenue cycle practice at Chadds Ford, PA-based IMA Consulting. "Multiple identities or possible fraud may be detected, including the identification of Social Security numbers for deceased persons," he adds.

Traditionally, access departments focused on address verification only, with batch address checking done after the fact. Newer systems give alerts if address and phone number discrepancies are noted, so these can be immediately corrected.

Camejo says to look for systems that also verify non-traditional phone numbers such as unlisted numbers or wireless, and integration with your ADT/practice management system. Ideally, he says, your system will highlight real-time discrepancies and allow the user to accept or reject changes after real-time discussion with the patient.

AT UPMC, outside vendors are used to review patient accounts to make sure that information on file is accurate. "And if we get a statement returned, we have an interface so it comes right back into our system," says Zilko. "At the point it's flagged as a bad address, we send it back out through the system to look for a good address."

If a good address can't be found, this means that some manual work is needed. "There is a little bit of manual intervention right now. So we're doing a little of both, but we are definitely looking at moving toward all electronic automated solutions for bad addresses," says Zilko.

The department also uses an automated process to check insurance eligibility. "We do that in a couple of different formats. We do that as batch for all our scheduled appointments, starting a few days prior to the appointment date, and we go all the way to the date of the appointment trying to get the most up-to-date insurance information," says Zilko.

Staff also check verification of insurance eligibility online. "This is also integrated back into our system. So when I'm on the phone with you making the appointment, if you have your insurance information available, I can go ahead and launch that right away to make sure you are eligible," says Zilko. "We also go straight to payers' web sites, using internal technology to bring that back into our patient management system." For all of these processes, timing is key. "We try to handle all of our insurance eligibility needs beforethe patient enters the building," says Zilko.

'Clean' registrations

To avoid denied claims, a "clean" patient registration without missing or inaccurate information is essential. "Our registration department works very closely with our 'back end' and billing partners. We find out the reasons for claims getting denied and how we can help on the front end," says Zilko.

Automation of collection efforts has contributed a great deal to this process. "Due to the fact that we have been able to clean up so much on our front end, we know we are dialing the right numbers. We know we are sending the statements to the right address. So that becomes a much better process," says Zilko.

Real-time edits were added to the patient management system to avoid incorrect or missing information that causes claims denials. "We have learned a lot about what type of denials we were getting, enough that we have been able to add in real-time edits. Now, if you format something incorrectly, it will stop you," says Zilko. "If there is a piece of information missing on a health coverage claim that is needed — a formatting or group number, for example — it will stop and ask you for that."

The department also has shifted its approach from asking individuals the same questions multiple times to simply verifying that information. "If we have done our homework prior to the appointment, especially for our returning patients, arrival should be a brief re-affirmation of the data that we have confirmed on file, and then immediate access to care," says Zilko.

[For more information, contact:

  • Ron Camejo, Director, Revenue Cycle Practice, IMA Consulting, Chadds Ford, PA. Phone: (484) 832-9940. E-mail: rcamejo@ima-consulting.com.
  • Karen Shaffer-Platt, Executive Director, Access/Information Services, Physician Division, University of Pittsburgh Medical Center. Phone: (412) 647-4912. Fax: (412) 647-3505. E-mail: plattkl@upmc.edu.
  • Diane Zilko, Senior Director, Physician Services Division, University of Pittsburgh Medical Center. Phone: (412) 432-5367. E-mail: zilkodh@upmc.edu.]