Stop denials for 'notice of admission'

If a patient is admitted at 10 a.m. Friday to Virtua Hospital in Marlton, NJ, members of the patient access staff have only until 10 a.m. Saturday to notify the insurance company.

"Previously, we had until the next business day, but we now have just 24 hours. Many of our insurance companies are really holding us accountable to that 24-hour mark," says Diane E. Mastalski, CHAA, CHAM, director of patient access. "When this occurs, it creates problems for many departments throughout the organization."

Tighter timeframes meant a major change in the role of Virtua's admission registrars, who are now responsible for notifying the insurance companies, instead of the insurance verification/financial planning team, she says. All admission registrars now complete the process for any patient they admit, which streamlines the process, Mastalski explains.

"In the past, we had to call each one in and give the insurance company the information. That meant waiting on the telephone and trying to get through," she says.

Most payers now accept electronic notification, adds Mastalski, and Horizon New Jersey Blue Cross/Blue Shield is set up to transmit the notification automatically through the electronic data interchange. "This speeds up the process for getting the information to the insurance company," says Mastalski. "However, we still have to wait for the authorization number, and that can take a day or more."

For this reason, members of the patient access staff are assigned to monitor the transmission reports from the hospital systems to the payer. "If a transaction kicks for any reason, that person is responsible to determine the cause and get the transaction resent," she says.

Work with case managers

The department leaders are looking into the possibility of transmitting notification electronically to more insurances through one technology solution, rather than using multiple solutions, Mastalski says.

Staff compliance is monitored on an ongoing basis, as failure to notify the insurance company within the appropriate timeframe can result in loss of revenue in the form of denied patient days for no authorization, she adds. "We work closely with our case management department. They let us know when there are fall outs," says Mastalski.

Some commercial payers have changed their notification requirements for inpatient bed status, reports Mary Frances Wood, RN, appeals case manager at Cook Children's Medical Center in Fort Worth, TX. As a result, case managers now assist in the process for making timely notification to avoid penalties.

"We are now tracking the amount of time patients have been in-house," Wood says. "This provides us with a window to make notification if an observation patient meets inpatient criteria and needs to be converted to inpatient status."

Sources

For more information on preventing claims denials due to incorrect patient status, contact:

• Diane E. Mastalski, CHAA, CHAM, Director of Patient Access, Virtua Hospital, Marlton, NJ. Phone: (856) 355-2155. Email: dmastalski@virtua.org.

• Mary Frances Wood, RN, Appeals Case Manager, Cook Children's Medical Center, Fort Worth, TX. Phone: (682) 885-1851. Fax: (682) 885-8442. Email: maryfrances.wood@cookchildrens.org.