Are payers giving you more hoops to jump?
Requirements are more stringent
As payer requirements become more numerous and stringent, any type of error can result in a needless claims denial.
"Since they keep changing, it is difficult to keep up. Many times, cards are not available," says Sheila Holzman, manager of Baltimore-based Mercy Medical Center's scheduling center, which handles pre-registration and insurance verification. "All the payers are offering numerous creative benefit packages with differing requirements. This is very confusing to keep track of."
Adding to the confusion is new terminology such as "opt out," which still requires authorizations and that the patient follows network requirements, but does not require referrals to specialists.
Payers have begun requiring notification five to seven days prior to scheduled procedures, when one or two days was typical. Without this notification, Holzman says, "They will technically deny the case. It has become very difficult to get physician offices to comply with this process. Hospitals can initiate the process with some payers, but the offices must submit clinical information. Most offices are still working one or two days prior to procedures."
In addition, insurers request that hospitals do not require payment on the new plans with high deductibles, and are using different criteria for utilization management.
For all of these reasons and more, keeping staff nearly error-free is a formidable challenge. "A key area of focus of our patient financial services/admitting department is to avoid denials altogether, in the first place," says Connie L. Arcella, patient financial services director at Banner Good Samaritan Medical Center in Phoenix. "It's our job to make sure an authorization is present, if one is required."
Avoidable denials
Arcella notes that staff must carefully follow guidelines for notification of an admission or admit status change within the timeline specified by the payer.
"To assist with this, we have what we call an insurance flow chart or matrix. This lists authorization requirements for each service," says Arcella. "It's our expectation that this guideline be followed." If the requirements are unclear for any reason, the payer is contacted for clarification.
"Though not all denials are avoidable, since an authorization is no guarantee of payment, we do our best to avoid them whenever possible," says Arcella.
At Lancaster (PA) General Hospital, updates on payer requirements are e-mailed to registrars directly by the patient financial services department. "Patient financial services also updates us daily on insurance changes," says Alesha N. Delgiacco, interim manager of inpatient access. "The more updates they provide, the more accurate we are."
Multiple payer-specific weblists are used, to be sure that staff have selected the most current insurance plan code that corresponds with the subscriber's insurance.
Delgiacco says that it is especially challenging to ensure compliance with payer requirements for emergency department visits.
"Each emergency room account created will bill within five days of service. So it's imperative to have the correct insurance plan added to the account at the initial point of service to avoid denials," says Delgiacco. "We average 108,000 visits a year in our ED. That's 108,000 accounts to code and ensure the appropriate insurance plan was added."
Communication is key
Commercial payers, says Maureen Moreno, manager of the PAFS contact center at Danbury (CT) Hospital, "are the ones that we have to stay on top of things with. One thing that's worked really well for us is creating centralized financial clearance. By doing this, we are able to communicate really well."
Dedicated staff review the accounts prior to service. They check for accurate patient information, that authorizations are done, and any patient balances have been collected or identified for the registrar to collect at the time of service.
"We had flags created in the registration system, and daily reports that allow the registrars to know the status of the accounts without having to review everything," says Moreno. Here are other ways staff are kept in the loop:
A daily e-mail updates staff on the status of the following day's accounts and what is needed, if anything, from the registration staff.
The contact center has a monthly meeting with all departments, including PAFS, outpatient registration, and business development, to report monthly and year-to-date totals. This is a chance to discuss any issues and brainstorm.
Throughout the year, business development, department managers, and the contact center meet with physician offices to discuss any issues and share any updates. "All physician offices have mine and the supervisor's direct phone numbers to contact us with any issues, questions or concerns so we can address them immediately," says Moreno.
Patient financial services has monthly meetings with the major payers and provides feedback.
The hospital's managed care department keeps patient access informed of changes in medical necessity, non-covered services, or payer requirements.
"As we look at new services that we have taken on, we are able to get to the nitty-gritty level with all of our payers," Moreno says. "Staff need to understand the rules and regulations that we have to follow in order to get payment, right down to the CPT codes."
It may be that in order to have a magnetic resonance imaging, the payer requires the patient to have an ultrasound first. "In the past couple of years, they've come up with these silly little hoops you have to jump through," says Moreno.
Another payer now requires authorization after a pregnant woman's fourth ultrasound. The problem is that the ultrasounds are done in multiple locations, including providers' offices, and may need to be done frequently with no advance notice. Right now, patient access has no way of knowing that the fourth test has been done. A process is being developed to address this.
"It's all about building relationships with physicians' offices, with patient financial services, and with departments," says Moreno. "Everybody has to have the same ultimate goal. We watch our denials, drill them down, and then figure out what we can learn from them."
To keep on top of these stringent, ever-changing requirements from payers, the department's staff are armed with toolkits. Any staff member can access the most up-to-date information on all payer requirements electronically.
"The toolkit contains anything and everything you need to know to schedule, financially clear, and register a patient," Moreno says. "It goes all the way down to the acceptable CPT codes for payers."
[For more information, contact:
Connie L. Arcella, Patient Financial Services Director, Banner Good Samaritan Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006. Phone: (602) 839-6697. Fax: (602) 839-4139. E-mail: [email protected].
Sheila Holzman, RN, CPAM, Manager, Scheduling Center, Mercy Medical Center, 301 St. Paul Place, Baltimore, MD 21202. Phone: (410) 783-5810. E-mail: [email protected].]
As payer requirements become more numerous and stringent, any type of error can result in a needless claims denial.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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