Trace claims denials back to provider offices
A patients may present for services without a referral required from his or her insurance company, or lacking a supporting diagnosis or procedure codes. These resulting claims denials are linked to the provider's office, along with prescriptions without diagnosis codes.
"Having the accurate ICD-9 code is critical in obtaining proper authorization and to receive appropriate payment from the insurance company," says Yolanda Martinez, corporate director of patient access at LibertyHealth in Jersey City, NJ. "The communication between patient access, patient accounting, and physicians are vital in avoiding or eliminating patient denials."
Martinez says that her department "goes above and beyond not to turn any patient away. So having an excellent rapport with the physicians and office staff is crucial."
The goal is to obtain all pertinent information during the pre-registration interview process. However, walk-in patients not scheduled for their appointments are also serviced, which may cause challenges.
"We call the physician offices and have referrals faxed to us or any other pertinent paperwork required, so as not to turn any patient away," says Martinez.
Staff painstakingly educate patients about their insurance requirements, to avoid delays and denials. "We explain the importance of having the physician document their diagnosis code on the script, obtaining a referral when required by their insurance company, and having the physician complete medical necessity for Medicare patients," says Martinez.
The access staff validate all Medicare codes during the pre-registration interview process. "However, we also validate codes as patients come in, to ensure payment from the insurance company," says Martinez. "If the codes are not appropriate for the exam, the physician is notified via phone for additional codes."
A fact sheet is handed to patients, which covers what type of bills they may receive. "This makes patients aware of the possibility of any physician not participating in their insurance," says Martinez.
Provider offices are invited to monthly meetings to keep them updated on new access service. The department is also implementing a system to give physicians the ability to request patient appointments from their own offices.
"This will allow the office staff to provide all necessary information via our scheduling system," says Martinez. "Communication will be improved, which is essential in providing service excellence to our patients."
At Danbury (CT) Hospital, "lunch and learns" keep both new hires and experienced staff up to date. "Representatives from clinical departments come in to discuss the type of service. This is so any patient access person can understand enough about the service to communicate better to the patient and to the physician's office," says Maureen Moreno, manager of the patient access financial services contact center.
When staff are first hired, a two-week training program includes spending time in clinical departments. "They get to see firsthand the services that they will be scheduling and clearing accounts for, and to meet the clinical staff to establish a relationship," says Moreno. "Obviously, they are not involved in performing the test, but they witness it and the technician explains it to them."
This gives staff a "visual," says Moreno, which helps them down the road when discussing specific CPT codes with payers and providers. "It also helps when talking to anxious patients who have concerns about a procedure," she says. "Staff are the first step to relieving that anxiety because they've seen the test they know what it looks like."
Danbury's scheduling system helps to prevent Medicare denials because it flags accounts that won't pass medical necessity requirements. When the physician's office gives a diagnosis code that doesn't meet the criteria, the schedule finds out then and there.
"Prior to this, there was no real way of checking the diagnosis code, other than looking it up on a piece of paper," she says. "If an ABN [advanced beneficiary notice] needed to be issued, but it wasn't known at the time and wasn't signed, Medicare wouldn't pay for it and we lost money."
This is known in "real time," so patients can sign the ABN prior to service, stating that they will become liable if Medicare doesn't pay. In some cases, a different kind of test might be performed instead, in order to meet medical necessity requirements.
"It is all done according to the guidelines, not just so Medicare will pay, but so that the patient gets the services they need," Moreno says.
[For more information, contact:
Yolanda Martinez, Corporate Director, Patient Access, LibertyHealth, Jersey City, NJ. Phone: (201) 915-2211. Fax: (201) 915-2558. E-mail: [email protected].]
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