Executive Summary
If providers’ offices have poor communication with patient access departments, patient satisfaction will suffer due to delayed care and unexpected out-of-pocket costs.
• Attend local office managers’ meetings in person.
• Meet with office staff to explain the problems that missing orders, codes, or authorizations cause.
• Establish A “Go-to” Person For Each Office.
Missing ICD-9 codes on orders were delaying care for patients at Riverside Walter Reed Hospital in Gloucester, VA, because payers required the codes to review claims for medical necessity. Instead of making a phone call to the provider’s office staff to explain why the codes were needed, Sherri D. Hamm, CHAM, manager of revenue cycle, went to speak with them in person.
“It improved the process a lot,” says Hamm, who reports that she began to see fewer issues over time. “It helps to talk face-to-face and put a face to a name,” she says.
Provider’s offices don’t always realize the process that patient access uses to ensure that authorization is in place before the patient arrives. Walter Reed, for example, has a Centralized Scheduling Center. “Within that center is an Insurance Verification office,” says Hamm. “But they do not obtain all authorizations for all facilities for all testing.”
Staff members in providers’ offices often are confused about which authorizations they need to obtain and which ones the insurance verification staff will handle. “On the flip side, it is good for us to know who obtains the auths in each practice, and the proper methods of communicating with that individual,” says Hamm.
Here are some ways patient access can collaborate with providers’ offices to prevent dissatisfied patients:
• Attend local office managers’ meetings.
“This provides two-way communication,” says Hamm. “It allows us to talk about hurdles that we face with one another in meeting the needs of our mutual patients.”
• Educate office staff on regulatory needs for proper documentation of medical necessity for labs and preoperative testing.
Surgeons sometimes used a diagnosis code that is related to the procedure the patient is having, instead of the laboratory testing. Payers refuse to pay for the laboratory testing, because there is no code to support the need for such testing.
“Delays take place when we have to call and inquire why the patient needs a CBC [complete blood count],” says Hamm. Payers will deny the claim if the diagnosis code for preoperative testing isn’t related to the surgery the patient is having.
“Medicare requires that the patient is notified in advance if the preoperative services are non-covered. The patient signs an Advanced Beneficiary Notice, which then holds the patient liable for the expense,” says Hamm. “Without this documentation, the denial results in a financial loss to the facility.”
Get on same page
Karen Watts, LPN, CHAA, a patient access specialist at Conway (SC) Medical Center, works with providers’ offices trying to obtain precertification, orders, and corrected orders.
“Working closely with the doctors’ offices helps to ensure that we are all on the same page with precertification,” says Watts. “We have to make sure that the office authorizes with the same CPT code that we are billing with.”
In the past, the CPT code would be similar to the CPT codes used for billing. “That no longer works with the insurance companies. We have to have the exact procedure coding as the office,” says Watts. “This has helped with not getting denials on our claims.”
Asking the office to send orders as soon as they can when booking a procedure helps to prevent delays. “If we do not have a correct diagnosis to meet medical necessity, or no signature on the order, we can send these back to be corrected, so that wait time is not an issue trying to get corrected orders at arrival time for the patient,” adds Watts.
Here is how she works with providers’ offices to prevent dissatisfied patients:
• Watts establishes a “go-to” person for each office and sometimes for each doctor in the office.
“Knowing how to get in touch with the right person for each situation saves wait time and frustration,” she says.
Watts keeps an ongoing list of physician names with phone numbers and extensions of nurses or precertification staff, and she includes the names of the next best person to get in touch with if the regular person is out. “To keep this list helps me to always call the correct person and also know the easiest way to contact them,” she says.
If the office staff members change roles or one of Watts’ contacts leaves, she immediately obtains the correct number to talk to the new person. “This helps to get to know each individual person that I am dealing with,” she says. “It lets me know if I should be very professional, soft spoken, or add a little humor to the situation.”
• She learns each office’s procedure for obtaining precertifications and orders.
“I try to stick with what works best for them and yet make it very smooth for my department as well,” she says.
Some offices send the orders with the patient instead of faxing them ahead of time. “If they prefer it that way, then we try to make sure that when preregistering the patient, the person has the order,” says Watts. Patient access staff then make sure everything is on the order correctly.
Some offices schedule the procedure after obtaining the authorization for the procedure and then fax the order. “This helps in not having to reschedule the patient if authorization has not been obtained by the appointment time,” says Watts. Other offices send the order to patient access, and they ask that patient access contact the patient to schedule the procedure. “We learn what is best for the office in handling scheduling and orders,” says Watts. “We try to make it a smooth process for them and us.”
Teaching the basics
• She teaches the office staff the basics of insurance.
“If I cannot meet with all the insurance clerks, I at least meet with the office manager so that this person is aware,” says Watts. “He or she can educate others at a later date.”
During the meetings, she reviews what procedures require authorization, whether various surgical procedures are considered inpatient and outpatient, and why medical necessity needs to be clear to avoid claims denials.
Watts also reviews what documentation is required with an order, how to handle outdated orders, and when the department expects to receive precertification for upcoming appointments, whether surgical cases or diagnostic studies. “We also require elements that identify the patient so we are not trying to guess who the patient is,” she says.
• She calls the offices the day before patients are scheduled to alert them of missing or incorrect orders, or authorizations that aren’t in place.
“I keep a log of needed items and send reminders via fax or phone, depending what the offices prefer,” says Watts. “If it is not corrected, we may have to reschedule the patient. But we do try to avoid it if possible.”
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Sherri D. Hamm, CHAM; Manager, Revenue Cycle, Riverside Walter Reed Hospital, Gloucester, VA. Phone: (804) 695-8581. Fax: (804) 695-8570. Email: [email protected].
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Karen Watts, LPN, CHAA, Patient Access Specialist, Conway (SC) Medical Center. Phone: (843) 234-6673. Fax: (843) 347-8216. Email: [email protected].
