Hospital cuts denials by 63% despite a surge in payers
More stringent requirements for auths means revamped processes needed
Patient access areas are seeing more procedures requiring authorization, a surge in the number of insured patients, and more clinical requirements from payers. All of these factors make an increase in claims denials - and much lost reimbursement - very likely.
"Without an educated and focused staff, lost revenue to the tune of tens of thousands of dollars can occur," warns Leigh A. Hunt, patient access manager for ambulatory services and the Patient Access Center at UK HealthCare in Lexington, KY.
Some payers now require a mid-level provider to do a peer-to-peer review before authorizing costly diagnostic tests such as stress echocardiograms, exercise cardiolites, and invasive procedures such as catheterizations and pacemaker/defibrillator implants, reports David Hoogenboom, CHAA, team lead/patient access liaison III at the Outpatient Access Department at Danbury (CT) Hospital. (See related stories on new requirements for clinical information, p. 39.)
Despite this requirement and other more stringent ones, Danbury Hospital's claims denials decreased by 63% between 2011 and 2013. One reason is the department's a double-check process, which ensures that peer-to-peers are completed. "Staff notify both the financial department that is responsible for obtaining the authorization and the doctor's office," says Hoogenboom.
If the patient is added on and needs to have their test the same day, it's often challenging to find a provider to take time out to do the peer-to-peer review. If this step is not completed prior to the service being rendered, a claim denial might result.
"The double-check process ensures that everyone is aware," says Hoogenboom. "The two departments can collaborate on a timeline for the peer-to-peer."
Over the past year, reports Hunt, "we have noticed a downward trend in our overall denials for registration categories by as much as 15%. We look forward to continue trending this number down." UK HealthCare's patient access leaders reduced denials with these processes:
. UK HealthCare's patient access center has a staff of 21 customer access associates who provide a detailed pre-screening for patients.
"An empowered and knowledgeable access staff is one of the best lines of defense against claim denials," says Hunt.
About 80% of ambulatory patients are pre-registered. They review these accounts for insurance, as well as correct demographic information, for each patient scheduled to come into the clinic, says Hunt. This process typically is done two days out from the appointment, so patient access staff can reach patients if there is any type of problem and enlist their help if needed.
. An accuracy audit is performed monthly on each pre-registration associate.
All items that could cause a claim denial are checked. "This ties directly into our performance evaluation criteria and monthly performance meetings," says Hunt.
. Patient access managers make sure each scheduling and registration agent is equipped with current and complete information on payer requirements.
"As we know, insurance plans are dynamic and ever-changing," says Hunt. "We, as managers, have to ensure that our staff who are dealing with these plans every day are as educated as possible."
Don't assume eligibility is unchanged
John Porter Jr., access denial analyst at Scripps Health in San Diego recently warned his staff that even information on file from even a week ago might be outdated.
"Some patients' eligibility changed three times in a three-month span," he says. "Keeping up with that has been hard on everyone."
Eligibility changes were a major challenge at the start of the new year, reports Porter. The expansion of Medi-Cal, California's Medicaid program, caused certain patients with local plans to be transitioned into Medi-Cal HMOs. "Many of these patients were not fully aware of the impact this had on their access to certain providers," says Porter.
These patients, and patients who purchased coverage on the Health Insurance Marketplace "can very easily end up attempting to access care outside of their network of approved providers," says Porter.
Verifying eligibility at every encounter is a central focus "to limit patients that have gone astray," says Porter. "When staff locate a patient out of their network, staff educate and redirect the patient as appropriate."
Requirements change often
The new exchange plans are another factor that could result in more denials, says Hoogenboom. Staff must now learn the methods for eligibility verification, how to look up a patient's benefits, and which services require authorization, for many more plans.
"If these steps are not followed and this information not learned, denials will definitely occur," says Hoogenboom.
The University of Tennessee Medical Center in Knoxville is seeing payer requirements change several times a year, says Sharon Bright, manager of patient access. "This is one of the main reasons for claims denials," she says. "To prevent the denials, we have to stay educated, updated and informed."
One way Bright handles this education is by signing up for insurance newsletters. She then sends a periodic email with updates to physicians' office managers. "The most important things to know are the precert requirements for each plan and how to access their websites to get information," Bright says.
Just because one particular insurer doesn't require authorization for a particular test doesn't mean that it won't soon require it. Hoogenboom says, "Keeping an accurate list of services that require authorization, and updating it regularly, is a necessity." (See related story on improving relationships with payer reps, p. 40.)
- For more information on preventing claims denials, contact:
- David Hoogenboom, CHAA, Team Lead/Patient Access Liaison III, Outpatient Access Department, Danbury (CT) Hospital. Phone: (203) 739-8200. Email: firstname.lastname@example.org.
- Leigh A. Hunt, Patient Access Manager, Ambulatory Services/Patient Access Center, UK HealthCare, Lexington, KY. Phone: (859) 323-3001. Fax: (859) 323-2021. Email: email@example.com.
- John Porter Jr., Access Denial Analyst, Scripps Health, San Diego. Phone: (858) 657-4048. Fax: (858) 587-4499. Email: