Not all denials are the fault of access

Many wrongly attributed to front end

Recently, a payer denied an $18,000 claim as non-covered services at Ochsner Health System in New Orleans, but this denial was challenged by patient access leaders.

"When we reviewed the case, we were able to show where the procedure was covered by the plan and our authorization and benefit verification supported that this should have been covered," says Stacy Calvaruso, CHAM, assistant vice president of patient management.

When the department's denial team researched it further, they found out that the provider had not updated their roster with the plan. "The service was a covered service, and if we would have just accepted this, then we would have lost out on $18,000 in reimbursement," says Calvaruso.

This case is an example of how patient access often is blamed for claims denials that other areas are responsible for, she says. "Approximately 25% of claim denials are actually not related to an action that the registrar did or did not do," she estimates. "It is problematic because the department is perceived negatively."

The trick is to look at denial reports with a critical eye, Calvaruso emphasizes. "When you really break this apart and look for areas that were controllable versus non-controllable, you see that many of the errors that are classified as front-end errors are really not," she says.

ID root causes

Calvaruso says that patient access leaders should review accounts in great detail to look for the error that resulted in a denial.

"Dig into your denial reports to ensure that you understand the root cause of the denials," she says. For example, an invalid authorization denial could be perceived as patient access not properly obtaining an authorization. "In actuality, it could be that the procedure performed was changed," says Calvaruso. Another reason for the denial could be that the service requires a specific work-up that was not disclosed by the payer upon the initial request for insurance verification and eligibility determination.

"Be sure that when the batches are coded, they are coded with the correct code; therefore, it falls to the appropriate responsible party," adds Calvaruso.

She works with the department's denials team to identify, by American National Standards Institute (ANSI) reason code, those items that are not typically related to patient access. "We go through each ANSI reason code by major plan," Calvaruso says. "This is very time-consuming, but very necessary."

After an initial review, Calvaruso asked the hospital's cash posting team to alert patient access on any new ANSI codes they receive. "An ANSI code may have a meaning for Plan A which could be different than what Plan X has interpreted," she says.

For example, Medicare gives a denial using ANSI code 50 for lack of medical necessity, while Humana uses ANSI code 96 but gives an additional remark code of N115 for lack of medical necessity denials.

"We challenge the denials team members on how accounts were processed," says Calvaruso. "We ask that they not accept the actual ANSI code, and truly look into whether or not the ANSI code was applied appropriately by the plan."

SOURCE

• Stacy Calvaruso, CHAM, Assistant Vice President, Patient Management, Ochsner Health System, New Orleans. Phone: (504) 842-6092. Fax: (504) 842-0516. E-mail: scalvaruso@ochsner.org.