Establish rapport with payer reps
It keeps you current with changes
Patient access managers must stay in contact with their assigned provider representatives and establish a good working relationship with these individuals, urges Leigh A. Hunt, patient access manager for ambulatory services and the Patient Access Center at UK HealthCare in Lexington, KY.
"They can be an invaluable resource in helping research and reduce claims denials," says Hunt. "They are the experts about their plans and have been involved in the contract set up for our enterprise."
For each plan, says Hunt, patient access areas need a "high-level understanding" of the plan's unique requirements for referral and pre-certification. "Study what causes certain plans to deny claims," she recommends. "Become vigilant in reviewing denial reports and knowing what causes a particular plan to deny. This will be different for each company."
The best approach is for patient access to have a good contact at each insurance company, says David Hoogenboom, CHAA, team lead/patient access liaison III at outpatient access department at Danbury (CT) Hospital. This approach allows the contacts to disseminate new information to staff in a more timely manner, Hoogenboom says. "Preventing denials requires accurate and complete fact-finding on the part of patient access," he says. "Much of this information will come from contacting an insurance company." These questions must be asked:
- Is the patient's coverage active and will it be active on the scheduled date of service?
- Is the hospital in-network with the patient's plan? "Some plans, including some EPO [exclusive provider organization] plans, have no out-of-network benefits," notes Hoogenboom.
- Is a referral required from the patient's primary care doctor?
- Is an authorization required for the ordered procedure?
- Does the patient have a copay for the service? Does their plan have a deductible? If so, how much has been met?
"As a new initiative, we try to collect at least a portion of deductibles at the time of service," reports Hoogenboom.
All of this information needs to be recorded in the patient's account with the insurance representative's name and a reference number for the call. This information is very important in the case of a denial, says Hoogenboom. When appealing the payer's decision, the denial can be contested with documentation of the information that a particular insurance representative provided.
"By following these steps, denials can be prevented - and when they do occur, successfully appealed," says Hoogenboom.