Correct status of patient's admission

Prevent claim from being denied

An incorrect admission status on a patient can cause a delay in obtaining a required authorization, warns Marsha Kedigh, RN, BS, MSM, director of admitting, ED registration, discharge station, and insurance management at Vanderbilt University Medical Center in Nashville, TN.

For example, if a Medicare patient is going to have a procedure that is listed as "inpatient only" with Medicare, the admission status might be listed as "observation."

"Authorization staff now have to contact the clinic, to inform them the status has to change to 'inpatient' before they can process it," says Kedigh.

Likewise, an authorization might be obtained for outpatient status, but the physician writes an admit order, adds Kedigh. "This creates a denial, as the authorization was for the initial status of outpatient," she says. "You will need to revise the reservations form to be sure the correct terminology is used."

Vanderbilt's patient access department is reviewing all aspects of the reservation process, including clinics, insurance management, utilization management, and operating room scheduling, reports Kedigh. To prevent problems obtaining authorizations, she recommends these practices:

• Have all clinics use an electronic reservation form instead of paper faxes.

Paper faxes can be misplaced and can't be tracked, she explains. "A standard electronic form, used by all clinics, gives more guidance for what is needed at the front end of the reservation process," says Kedigh. "This streamlines the authorization process."

It is easier to hold staff accountable for their practice if all clinics process their reservations in the same manner, she says. "The expectation to obtain authorization in a timely manner increases when all the required elements are understood and in place when authorization begins," she says.

• Provide clinics with a list of needed items to obtain authorizations.

"So scheduling staff may refer to these when indicated," says Kedigh. "This ensures what is required on the initial submission of the reservation is present in the [electronic medical record]."

• Meet with clinic leadership to update them on issues that affect the authorization process.

"Give specific examples of cases from their clinic that created delays in obtaining the authorization," advises Kedigh.