Knowledge (of denials) is power; integrated database provides it

Tracking and teamwork make the difference at Brigham & Women’s

If you think your hospital doesn’t have a problem with denials and you aren’t doing anything to track them, Christine Collins, CHAM, strongly suggests that you just don’t know one way or the other. The heart of successful denial management, emphasizes Collins, who is director of patient access for Boston’s Brigham & Women’s Hospital, is a denial database, which categorizes the bills that are denied and the reasons why. With the challenges of clinical vs. administrative denials, observation vs. inpatient status denials, and complicated time-sensitive authorization processes, she adds, the cash flow can be difficult to follow.

To get a handle on what wasn’t getting paid and why, the hospital formed an inpatient denial team — co-chaired by Collins and a physician — to oversee the process, with representation from patient access, billing, medical records, and care coordination. Boston-based Partners Healthcare system, of which Brigham & Women’s Hospital is a member, awarded the team a 2001 Partners in Excellence Award for outstanding efforts in improving management of denials. Collins says the team continues to be recognized for its achievements.

Building a denial database was the first order of business, she says. An analyst in the patient access department provides upkeep of the database, while the following areas handle other functions:

  • Care coordination — provides analysis of clinical/utilization review denials.
  • Patient access — assesses authorization processes.
  • Patient accounts — pursues final outcome.
  • Medical records — handles documentation needs.
  • Medical director — handles clinical appeals.

The process begins, she explains, when accounts receivable gets a denial and puts it into the data-base, assigning it to a person based on the kind of denial it is. "What we do that’s wonderful," Collins notes, "is assign denials so we can track them. If [a denial] comes to my office, but is clinical, I reassign it to a person who can handle it. If it’s a pre-cert or preauthorization [issue], it’s assigned to my staff."

IT drives the process

"Most hospitals," she adds, "don’t have the IT [information technology] to have this information at their fingertips — [information about] who’s working what."

Pat O’Keefe, denial manager in patient access services, is in charge of handling all technical and administrative denials, Collins says, and at times works very closely with care coordination personnel. "In every area, care coordination has one or two people who own this [denial management] process." O’Keefe says she consults with utilization review nurses to determine whether a patient has inpatient or observation status, which often is a point of contention with insurance companies responding to claims. On a day-to-day basis, O’Keefe notes, she is responsible for researching any (technical and administrative) denials that are related to inpatient admission. "[That includes] writing the appeal and getting any kind of documentation I need to support our case."

"If we believe we followed the proper procedure, that means doing screen prints of notes saying who we spoke to [at the insurance company], what authorization number we got, and also getting any necessary medical documentation, and sending it off to the insurance company," she says.

Even in the case of technical or administrative denials, O’Keefe says, many insurance companies require that a patient’s medical record accompany the appeal. "I have a spreadsheet that I’ve developed," she adds, "and every time I send out an appeal, I enter it on the spreadsheet so I can keep a running total, including what the status is, if an appeal is still out." Her practice always is to send appeals by certified mail, O’Keefe says. "It doesn’t always work, but it’s much better than not having a receipt."

Timely payment, improved processes

Collins is reluctant to make before-and-after comparisons regarding dollars recouped by the denial management initiative. A reimbursement denial that’s now quickly reversed via the new denial management process eventually might have been handled successfully through appeals, she points out. "[In the past] if we had these denials and weren’t tracking them but did a lot of legwork and eventually got paid anyway, it might have taken six months instead of six weeks," Collins says. "In the old days, and still at many hospitals, people in accounts receivable are constantly resubmitting bills."

The beauty of the tracking process, she adds, has been in the ability to notice trends, improve processes, and work with payers on better system-to-system communication. "Data is so powerful," Collins notes. "Until you have that, you’re looking at [denials] one by one. Once we track them, we have the documentation to support why we shouldn’t have been denied. Settlements with payers can be made based on data. We maintain all the documentation on-line, and we follow up denied claims until resolution."

Within the database, there is the capacity for electronic communication to prompt steps in the appeal process, she says. "If we notice that something is a trend and should not be a denial, we can include that in the next contract negotiation," Collins says. "For instance, most payers want you [in maternity cases] not only to authorize the mother, but also the infant. There are all sorts of issues with payers and newborns."

Problems lead to solutions

Examining individual problems can lead to long-term solutions in other areas. Some redundancies in the preauthorization process can be beneficial to the payer as well as the hospital, she points out. "They want to make their administrative burden smaller, too."

With one payer, O’Keefe notes, the hospital has been able to negotiate that authorization is not required for mother or baby if the baby is born at Brigham & Women’s. "We still need [authorization] if the baby is born elsewhere and transferred here." Having made this inroad with one insurance company, the hospital cites it as a precedent in talks with other payers, she adds. "The idea [behind eliminating the authorization requirement] is that the insurer knows the women are pregnant, and that they will be coming to the hospital — they may even be having their OB [obstetrics] visits here."

While in the past a payer might contend that the hospital never had made a preauthorization call on a particular case, the capacity for electronic communication puts the accountability on both sides, Collins points out. "When we start to do an autopsy on denials, we say, Gee, their system has its own problems.’ Sometimes what we have here is different from what they think. If you don’t dot an I’ on one system, the other system kicks [the bill] out."

With one insurance company, O’Keefe says, the hospital was having a difficult time with maternity admissions because the insurance company consistently said that the first day of the hospital stay was not approved. "As we analyzed it, we saw that the women in those cases came in one day, were in labor and delivery, and then delivered the next day," she adds. "This insurance company had someone who — when we called to notify them of a delivery — was listing that day as the admission day."

When the insurance company was provided with data showing it was a payer problem, O’Keefe explains, it took responsibility and corrected the claims without making the hospital go through the appeals process. That is significant, she says, because of the extraordinary length of time that process can take. "When we first started doing appeals, [the payers] had not had a lot of hospitals doing them," O’Keefe adds. "It would take five months or longer for them to acknowledge that we’d sent an appeal. Then they would send a letter saying we would be notified in 45 days."

Tracking denials prevents certain groups of patients from slipping through the cracks in the admitting/screening process, she notes. In the past, patients could be in and out of the ED in the middle of the night and even though there was a service that required a different authorization their names might not appear on the admitting list, O’Keefe explains. Now, she says, those cases are tracked, billed in a timely manner, and there is no need to work later to reverse a denial that might otherwise have occurred.

What Brigham & Women’s system provides, Collins points out, "is more understanding so we can improve our process. Until you have a common, integrated database that is completely open, honest, and hospitalwide, you’re not going to have that. "It’s the little things," she adds. "It’s truly understanding the business and what the issues are, and [asking] how can we fix them."

[Editor’s note: Chris Collins can be reached at (617) 732-7453 or cfcollins@partners.org. Pat O’Keefe can be reached at pokeefe@partners.org.]