Avoid denials — Get it right from start

When an interdisciplinary team including patient access, insurance verification, and radiology personnel was formed to reduce claims denials, "realizing where denials are coming from was definitely our first step," reports Brian A. Todd, CHAM, manager of patient access staff development and training at Lourdes Health System in Camden, NJ.

Here are changes that were made:

• Communication was improved between insurance verification and the clinical departments.

First, members of the patient access staff call the physician's office to obtain a new order for the additional study, which is immediately faxed up to the insurance verification personnel.

"This catches those procedures that must be done for the patient but were not included in the initial procedure schedules," says Todd. "If applicable, an authorization is then sought."

• Patient-friendly scripting is used, in the event that a patient cannot have the additional services performed due to insurance requirements.

Access staff state, "There is an additional study that we and your physician would like to have you have done. However, it does need to be scheduled with our scheduling department prior to us performing it. They will make every effort to get you scheduled for this additional study on a date and time that is convenient for you."

"This type of 'patient-first' verbiage ensures that the patient doesn't feel like some monetary factor is standing in the way of their testing," says Todd. "The patient knows their healthcare is important to us, and we are protecting the financial viability of the organization."

• The importance of "getting it right from the start" is emphasized.

"Our schedulers are kept up to date on all procedure changes that would affect how they would process and offer an appointment to a patient," says Todd.

Schedulers work with a "cheat sheet" so they can reference the insurance requirements at the point of scheduling. If an authorization is required, for example, it wouldn't be in the patient's best interest to schedule a procedure for the following day when it can take up to five business days to obtain the proper certification. "This concern is expressed to the patient as well, so everybody is on the same page," Todd says. "For patients where there are no insurance requirements, though, we seek to get the patient an appointment as early as the very next available day."

• Staff make sure the doctor, the organization, and the insurance company are "on the same page" with the description of the testing requested.

"With us not necessarily being CPT code experts, the description on the patient's script may not necessarily match the description in the CPT book," says Todd. "Ultimately, the insurance companies are referring to the test by that CPT number, so our effort is spent on making sure everything is 'matchy- matchy.'"