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Forced to invest significant resources trying to overturn all these denials, patient access departments are searching for the most efficient and effective way to do it.
Some denials can be overturned easily — maybe a piece of clinical documentation is missing. Other denials are a long shot, requiring lots of time and effort to challenge. For one Philadelphia-based health system, no mountain is too high to climb.
“Bad news travels fast, and good news travels more slowly ... It’s a major problem, and it will take years to unwind the anxieties that have been created.”
Researchers analyzed Medicaid claims data from 2017. They found 22.9% of patients with a homelessness code experienced coverage interruption at least once vs. 18.8% of Medicaid patients without a homelessness code. Other common reasons people lose their Medicaid coverage include income changes, residency changes, the insured is no longer pregnant, the insured’s children age out, noncompliance with status updates, or the insured is no longer disabled.
Delays can be caused by slow registrars, the need for interpreters, too many patients scheduled at the same time, or talkative patients, among many other things. To cut wait times, two centers in North Carolina have tackled these issues and more.
Some patients clearly meet the medical criteria for a hospital admission. Despite this, the health plan refuses to pay the claim — because staff did not notify the health plan soon enough.
Admission notification denials are no longer happening at Moffitt Cancer Center in Tampa, FL, thanks to collaboration between patient access and case managers.
With nearly 20 settlements so far, the Office for Civil Rights is showing its determination to protect patients’ rights to obtain their medical records from healthcare entities.
At press time, OCR had settled five Right of Access investigations so far in 2021, four of those since President Biden was sworn in to office on Jan. 20.
Healthcare professionals can find themselves in a quandary when they want to report fraud or other concerns within their organizations because doing so could require disclosure of protected health information. That could seem like a HIPAA violation; fortunately, there is a whistleblower exception that covers this scenario.
