Payer mix soon will be more complex

Denials reduced by 30%

Within one year, the patient access department at Advocate Illinois Masonic Medical Center, a 408-bed hospital in Chicago, reduced denials due to no benefit coverage and no authorization by 30%.

"As carriers become more aggressive with their requirements, we had to look at many tactics to stay ahead of the game, while still reducing denials," says Philip N. Quick, CHAM, manager of patient access and bed management.

With healthcare reform on the horizon, says Quick, the department already has put new processes and technology in place. The goal, he explains, is for the department to handle not only increased volume, but also the complexities of the various payers and changing payer mix. "More and more emphasis is put on the front-end revenue cycle processes," says Quick. "Our focus will continue to be on financial advocacy."

Quick is working with technology vendors to ensure his staff members receive complete and accurate benefit information from payers. "We have great partnerships with our vendors," he says.

Patient access has standing monthly meetings with its integrated eligibility vendor to review any problem areas, status updates, and product enhancements, he adds. To reduce denials, the department made these changes:

• On the outpatient side, patient access educated physicians on the requirements for various payers.

"We are able to be proactive much earlier, allowing time to obtain verification and pre-certification if necessary," says Quick. "This reduces the amount of re-work and increases the clean claim rate."

• Bed management was merged with inpatient insurance verification, which allowed for real-time verification.

This change allows for a seamless handoff between the previously segregated units and real-time verification of benefits at the time of the admission order and status changes, says Quick.

"In the previous environment, there was often a delay in verification or authorization of benefits," says Quick. "We relied heavily on face sheets as the primary work driver. Merging these two units streamlined the whole inpatient process."

Uninsured or underinsured patients are connected with financial counselors much earlier in their stay. "There are no surprises with their benefit coverage. Patients can concentrate on their clinical care," Quick says.

• An electronic workflow solution is used in inpatient and outpatient verification areas.

The tool receives data from the admissions/discharge/transfer system and the scheduling system, which allows for transparency of information between patient accounts, utilization review, and case management, says Quick. It also allows the verifiers to customize their patient work list by date of service, payer, or alphabetically.

"Staff also have the ability to escalate problem accounts to their immediate supervisor," says Quick. "Accounts that are delayed in obtaining authorization due to barriers on the payer side are quickly identified. We are able to quantify and isolate them."

Supervisors are able to track productivity and quality more efficiently. "We can quickly drill down and provide this information to each associate," says Quick. "As part of our department's 'green' initiative, the reduction in paper costs have been significant. This allows us to shave off a considerable percentage in our controllable operating expenses."

Sources

For more information on payer requirements, contact:

• Philip N. Quick, CHAM, Manager, Patient Access and Bed Management, Advocate Illinois Masonic Medical Center, Chicago. Phone: (773) 296-8303. Fax: (773) 296-8119. E-mail: philip.quick@advocatehealth.com.