Stop 'no auths' due to changed procedures
EXECUTIVE SUMMARY
Often, claims are denied for failure to obtain the required authorization, simply because a different clinical procedure or diagnostic was done. Patient access leaders at Lourdes Health System addressed these denials with these approaches:
• Cardiologists were informed about the denied claims.
• The director of OR services and surgeons were asked to notify payers of procedure changes.
• New processes were put into place to obtain authorizations prior to service.
When hospital VIPs at Lourdes Health System in Camden, NJ, expressed concern over the fact there were so many claims denials for no authorization, Joan Braveman, corporate director of patient access, asked for data. She began studying the "no auth" denials.
"I kept hearing we had too many denials, but I wanted to get some good data on what was going on," she says. Once data were obtained, Braveman noticed a cluster of accounts that did, in fact, have authorizations but were still denied for no authorization. Further analysis of the accounts showed that authorizations had been obtained for specific services, but other services were provided.
"In many cases, the surgeon or cardiologist had obtained an authorization, and then performed a different service," she says. "Since no one notified the payer of the changes, the claims were denied."
In-person visits
Now that one cause for many of the no authorization denials was identified, an action plan needed to be developed. Since most of the services were provided in either the OR or the heart catheterization lab, Braveman decided to educate the departments. She went to the cardiology groups in person to inform them of the reason so many of their claims were being denied.
"In some cases, it was something as simple as obtaining an authorization for a cardiac cath, and then the cardiologist finds the patient needs a stent," she says. "If they don't notify the payer of that change, the claim will be denied."
Next, Braveman worked with the director of OR services so she could educate the OR staff about the problem. Now, if they see a patient is scheduled for a certain procedure, but the surgeon does something different, OR services staff notify the payer of the change in procedure so the authorization can be obtained. In some cases, the original procedure didn't require an authorization, but the procedure provided does require an authorization. Again, the physicians' offices are asked to notify the payers within 48 hours, as required by some contracts.
Braveman also asked the billing office send her all "no-auth" denials that do have an authorization number in the system, so these can be addressed and appealed right away.
Very costly writeoffs
In addition to the claims denials, Braveman learned that a large number of write-offs were occurring for cardiology services.
"Since cardiology procedures are generally costly procedures, I decided to do further research on these accounts and write-offs," she says.
In some cases, it was found that the patient came in for a lead replacement in an automatic implantable cardioverter defibrillator (AICD) and the cardiologist decided there was a need to replace the AICD, but no one was informing the payer.
Braveman alerted the cardiologist groups about this costly problem. "I told them, 'If the authorization gets changed for the service provided, everybody gets paid,'" she says.
She told the groups about two recent cases that were written off, which each cost the hospital about $30,000 in reimbursement. One case involved a generator replacement with an authorization in place only for removal. The other case was a pacemaker removal which didn't have an authorization in place. "For either of those cases, a phone call at the right moment to the insurance company would have taken care of it," she says.
Because Braveman educated the cardiology groups, there have been fewer "no-auth" denials for cardiology patients. In addition, new processes were put in place to obtain authorization before the patient presents for services, and for patients transferred for cardiac catheterizations.
"We were getting bad information from the sending hospital on the patient's insurance, and then we weren't getting paid," explains Braveman. (See related stories below on claims denials involving Medicare and avoiding costly radiology writeoffs.)
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SOURCES
• Joan Braveman, Corporate Director, Patient Access, Lourdes Health System, Camden, NJ. Phone: (856) 757-3676. Email: [email protected].
• Kim Gehl, Manager, Patient Access/Central Scheduling/Central Precertification, Wheaton Franciscan Healthcare, Milwaukee, WI. Phone: (414) 527-5010. Fax: (414) 527-5005. Email: [email protected].
• Cindy Thomas Lowe, CHAM, Patient Access Director, Danbury (CT) Hospital. Phone: (203) 739-8204. Fax: (203) 739-1905. Email: [email protected].
When hospital VIPs at Lourdes Health System in Camden, NJ, expressed concern over the fact there were so many claims denials for no authorization, Joan Braveman, corporate director of patient access, asked for data. She began studying the "no auth" denials.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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