Denials cut with this process

Previously, 10 to 20 claims were denied each month at WakeMedHealth and Hospitals in Raleigh, NC because of failure to notify the payer.

"Now, we have less than five denials per month related to notification," reports Natalie Uy, RN, BSN, CCM, manager of patient access and emergency department registration. "Most of these denials are due to late discovery of insurance or unjustified penalties." Here is the process used by patient access staff:

For urgent/emergent admissions that present to the hospital through the emergency department, direct admission from the physician office, from home, or transferred from other hospitals:

1. The insurance verification team, which is part of patient access, verifies the insurance coverage and eligibility.

2. The team notifies the insurance company of the admission electronically, via fax, or by telephone.

3. If clinical information is required, the team notifies case management. "If the insurance company has not assigned a case manager to the case, we provide the insurance company the contact number for our case management department, which provides the needed clinical information," says Uy.

For scheduled cases:

1. Physician offices contact the third party payers to initiate the prior authorization process.

2. The insurance verification team verifies the insurance eligibility and coverage, the presence of the authorization, and the team confirms that it matches the procedure/service.

3. The team contacts the physician office if a required authorization has not been initiated.

"If case is not authorized, and the physician office is still working the case and does not want to postpone the case, or if the patient insists on having the service, we have the patient sign an advance beneficiary notice," says Uy.

4. The team notifies the insurance company on the day of admission, if this information is required by the payer.