$2.6M more revenue captured with audits
Denials cut to only .08%
Patient access leaders at Florida Hospital in Orlando don’t spend much time auditing denied claims, because there simply aren’t many of them. The department has a current denial rate of just .08%.
"We began this process in 2002. In that year, we wrote off $4.5 million or .42%," says Bonnie Hache, administrative director of patient access. "If we were still at that rate, we would have written off almost $10 million in 2012."
In 2012, the hospital wrote off $1.9 million. "The Healthcare Advisory Board reports hospitals run at an average of .8%. That would represent $18 million for Florida Hospital," says Hache.
Hache credits her department’s success to being "very intentional in reviewing why mistakes are made and training our staff. If you don’t take the time to do that, you will not improve." The department’s "denial avoidance process" includes weekly meetings at which every denial of more than $1,000 is reviewed in detail. "Then, we meet with reps on an individual level so they can figure out what they did wrong," she says.
Staff members stay on top of all changes, such as a recent trend toward payers requiring more clinical information to meet requirements for medical necessity. Many times, an authorization is no longer enough. Payers want to review all the physician’s records on the patient to ensure all steps have been taken to avoid a high-cost test.
"Insurance companies are looking much closer at every service we provide and hold us to a much higher standard for obtaining authorizations," says Hache.
Florida Hospital’s patient access management and other members of the denial avoidance team routinely round in clinical areas to discuss issues causing denials.
"We are leaders in this area, but it is only by working together," says Hache. "We make sure we are meeting their needs, and we listen to what they say."
Clinical areas openly discuss the challenges they are facing working with physicians, for example. "Their assistance in speaking with physicians regarding services that are not covered is instrumental in making changes," says Hache. Recently, Hache made clinical areas aware of these reasons for denied claims:
- Some payers require a CT scan to be done before a positron emission tomography (PET) scan will be authorized.
- Some payers require documentation of alternative approaches before authorizing physical therapy, such as taking anti-inflammatories for a specific amount of time.
"We take account-level information back to them," she says. "We share with them what was missed, and discuss what they can provide to us in the future."
Hache doesn’t think investment in technology to audit denials would be cost-effective at this point in time, since denials are so few.
The manual process used by the department was very labor-intensive at first, but it is much more manageable due to the low error rate, she reports. "We have no plans to automate this process," she says. "Our denials are so low that to spend a lot of money on technology doesn’t make sense," she says.
Last year, "no auth" denials totaled just $250,000. Most of these occurred because of mistakes made by patient access representatives, such as taking the provider’s office’s word that no authorization was required instead of calling the payer directly.
"Those are mistakes that even technology couldn’t help us with. Some human error will occur," she says.