Make needless claims denials a thing of the past with staff involvement

Turn mistakes into a 'teaching moment'

Too many claims denials lead to loss of revenue and unhappy administrators — two things no patient access department can afford, especially in this economy.

"Denials from commercial carriers are always a challenge," says Frank Danza, vice president of revenue cycle management at North Shore-Long Island Jewish Health System in Great Neck, NY. "Our patient access areas must be diligent to make sure we have accurate insurance and proper authorizations on every case."

Danza says this is true for all points of access, whether a case is scheduled, emergent through the ED, or transferred from another facility. "Each situation presents its own set of challenges," he says.

Revamp claim review

At Good Samaritan Medical Center in Brockton, MA, the patient access department recently upgraded its denial management system. Claims for all payers are now reviewed prior to submission to the insurer.

"We started slowly, with only a couple of payers," says Eric Akesson, director of patient financial services. "We noticed a decrease in denials and an improvement on the overall speed in which claims are processed for these payers."

Akesson says he expects this to continue as the use of the tool is expanded. "The data received on potential denials have also been very helpful in educating staff on recurring errors," he adds.

According to Julianne Flammia, the hospital's director of patient access, the biggest problem from an access standpoint is that incorrect insurance information from a previous visit can occasionally be retrieved and used multiple times.

"If your system carries forward incorrect demographic information to future visits, the problem will be compounded on multiple visits," says Flammia. "It is imperative to have a tool in place to verify all insurance data at the time of scheduling or registration to reduce these denials."

Staff correct mistakes

Good Samaritan's patient access department uses a system with quality assurance functionality that monitors eligibility and verification errors prior to claim submission. These errors are self-reported, and corrected by the patient access coordinator prior to the claim submission.

"The registration staff are so busy and under tremendous pressure to register a patient quickly and accurately," says Flammia. "Correcting their own errors helps the staff to recognize the correct mnemonic to use, how a policy number should be entered, and how it should look. They will learn the proper way an insurance must be entered."

Reports are created for individual staff members, showing the type and amount of denials received. "These data can then be used to conduct a teaching moment with the individual regarding these mistakes," says Flammia.

Previously, claims denials were corrected later in the process by the billing office. Thus, the access staff who made the mistake were out of the loop. "Communication between both departments will help to educate the front-end staff going forward," says Flammia.

By reviewing claims before they are sent to the insurer, the facility is alerted about a potential denial based on the specific provider requirements. "This helps keep total denials at a minimum, though you will never be able to completely remove denials from the billing cycle," says Akesson.

Akesson says the most important feature is a tool that reviews multiple payers that is supported on a regular basis as insurers are constantly changing their requirements.

"If you do not stay current with these changes, you will definitely see an increase in your denials, no matter how robust your original tool was," says Akesson. "A tool needs to be updated on a regular basis to catch all of these changes."

Proven approaches

Gayle Dickerson, patient access director at Baptist Hospital East in Louisville, KY, says her department has reduced claims denials with these approaches:

• moving to online verification of insurance coverage at the time of registration;

• verifying pre-certification requirements online, and ensuring these are correct for the procedure being performed;

• having a high percentage of preadmitted patients. "This allows ample time to verify coverage and pre-certifications for scheduled tests, procedures, and admissions," says Dickerson.

At Methodist Charlton Medical Center in Dallas, all scheduled and admitted patient accounts are reviewed within 24 hours of admission. Staff verify that authorization and referral has been obtained by the financial counseling staff.

"For those insurance providers that we have online access to, we scan the authorization into our registration system," says Jeanette Foulk, director of admitting/discharge. "For those that are done via phone, reference numbers are requested." The name of the representative who provided the information is always documented.

For outpatient scheduled appointments, this process is followed:

• A list of all scheduled procedures is printed every day.

• All accounts are verified by management.

• Staff verify that an authorization number has been obtained and is noted in the authorization field.

• Staff verify that a referral has been obtained, if needed.

• If authorization is not obtained, the account is referred back to a financial counselor for completion. It is returned to management when completed, for verification.

For inpatients, a similar process is followed:

• An inpatient insurance worklist is printed.

• All admissions are verified for authorization within 24 hours.

• Staff verify that authorization has been obtained or noted as "pending, due to clinicals requested."

• If authorization is not obtained, the account is referred back to a financial counselor for completion.

Registration and financial counselors have access to a database, which contains updates and changes by insurance plans for easy reference. "It is hard to keep current with all of the payer requirements," acknowledges Foulk.

Involve physicians

Sometimes, authorization is not obtained because the requesting physician failed to contact the insurance plan. "When this occurs, we contact the requesting physician and request follow-up as soon as possible," says Foulk.

If authorization is still not obtained at the time of the procedure, the patient is notified of a possible delay in the procedure due to failure to receive authorization.

"The patient may be asked to reschedule until we receive authorization provided by the referring physician," says Foulk. "The exception to this is if the [patient's procedure] is considered an urgent or emergent procedure."

Dickerson says that her staff work directly with physician offices to verify that the diagnosis covers the test or procedure being performed. "We ensure that the precert matches the test exactly. We make corrections as necessary," says Dickerson. This is sometimes done the day after the test, but always within 48 hours.

"This has proved to be very effective in decreasing denials. There's an exact match, and the claim processes cleanly," says Dickerson. "Also, working with physician offices helps them understand what happens on the hospital side."

[For more information, contact: Frank Danza, Vice President, Revenue Cycle Management, North Shore-Long Island Jewish Health System,145 Community Drive, Great Neck, NY 11021. E-mail: FDanza@NSHS.edu; Gayle Dickerson, Patient Access Director, Baptist Hospital East, 4000 Kresge Way, Louisville, KY 40207. E-mail: Gdickerson@BHSI.com; Jeanette Foulk, Admitting/Discharge Director, Methodist Charlton Medical Center, 3500 W Wheatland Road, Dallas, TX 75237. Phone: (214) 947-7560. E-mail: JeanetteFoulk@mhd.com.]