EXECUTIVE SUMMARY
- Write-offs resulting from errors made by patient access were cut in half at Saint Louis (MO) University Hospital. After identifying root causes of denials, the department made changes.
- Staff compare what was approved with what is billed, to identify additional CPT codes.
- Technicians are to obtain authorizations for each CPT code.
- Patient access contacts physicians’ offices at least seven days before scheduled procedures.
Write-offs due to mistakes made by patient access employees were cut in half at Saint Louis (MO) University Hospital by determining the root cause of insurance eligibility claims.
“Patient access write-offs in 2013 were $212,499, and in 2014 they were $92,533,” reports Lillian Cortivo, director of patient access services.
The billing department provides a list of disputed claims to patient access and case management. “We meet weekly to identify trends to eliminate for the accounts being disputed,” says Cortivo.
Here are two problems they identified:
1. Denials often occurred because an authorization was given for one CPT code, but an additional procedure was performed.
“That is one of the biggest reasons for claims denials,” Cortivo says. “We have done a few things to address this.” These changes were made:
- Every day, the department receives a report showing the CPT codes that were authorized.
“It shows what was approved and what is being billed out,” says Cortivo. “If there is any difference, it will catch it before insurance receives it.”
- If needed, patient access employees quickly contact the payer to get the authorization updated.
“Usually if we catch it the day of the procedure, the insurance will give the authorization. On a few occasions, they won’t,” says Cortivo.
- Patient access educated technicians in ancillary departments about the need to obtain authorizations for every CPT code.
“If the technician sees something is added, they contact patient access right away. We then contact the insurance company to get that authorization,” says Cortivo.
- Patient access contacts physician offices at least seven days prior to scheduled procedures, to make sure required authorizations are in place.
Staff members document on each account, “This authorization is for these codes.” “If the facility identifies that the auth is not in place for a specific code, we contact the provider office,” says Cortivo. “They update the auth to capture the code.”
2. Some claims were denied for patients admitted through the emergency department because patient access couldn’t get the insurance information upfront.
If the patient is moved to a rehabilitation facility, patient access typically doesn’t get the information until several days later. “We document each and every time we attempt to visit a patient and attempt to collect that information,” says Cortivo. “Usually if we can prove we didn’t have the information, they will pay the claim.”
Patient access leaders at Wilmington, DE-based Nemours/Alfred I. duPont Hospital for Children are closely monitoring “no-auth” denials.
“We recently split them into more focused categories to assist with solving the underlying issue for the denial,” says Lisa Adkins, MSN, RN, CPNP, CRCR, director of patient authorization/care management.
Denials are put into these categories: payer is not participating, code changes in which one code was authorized but a different code was billed, and capitated lab/imaging site denials. “Denials lumped into one big ‘no-auth’ category did not allow us to understand why the visit or procedure was denied,” says Atkins.
A “code changes” spreadsheet is used by the authorization specialists and the outpatient procedure coder. “The coder is able to quickly add cases to the spreadsheet for the auth specialists to work daily, to request authorization for the changed or added codes,” Adkins explains.
Previously, staff allowed the additional code to bill, then appealed the “no-auth” denial on the back end. The new process lets the added procedures get authorized on the front end. “It’s not perfect, as some payers have strict timelines on requests,” says Adkins. “But we have seen a definite improvement.”
The department also changed its primary care physician referral process. “The improved referral process decreases the amount of time it takes to submit the referral,” Adkins says. “It also decreases errors in transcription.” This process leads to fewer claim denials for no authorization or incorrect codes.
Previously, staff manually printed and faxed the referral. For imaging studies, staff members called the provider’s office the day of the visit to authorize the test. “Now all faxing is completed within the Epic system, with no need to get up and wait in line for the central fax machine,” says Adkins.
The department also developed a referral request form that automatically pulls in patient demographic info, which saves time and improves accuracy. This form is sent to the primary care physician requesting the referral.
“We are also working with different services to get a better understanding of imaging or lab studies that are typically ordered with a specific diagnosis, such as fractures,” says Adkins. A return visit for a fracture results in an X-ray 95% of the time, for example. “We are developing a tool to assist the authorization specialist in knowing what to request to authorize the appropriate X-ray,” says Adkins.
SOURCES
- Lisa Adkins, MSN, RN, CPNP, CRCR, Director, Patient Authorization/Care Management, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Email: [email protected].
- Lillian Cortivo, Director, Patient Access Services, Saint Louis (MO) University Hospital. Phone: (314) 268-5086. Email: [email protected].