Stop 'no auths' due to changed procedures |…

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.)

Medicare is primary, but claim still denied?

Sometimes an insurance verification system says a patient's Medicare coverage is secondary, but patient access staff members know otherwise. Rita Ascencio, insurance manager at Lourdes Health System in Camden, NJ, doesn't just ask patients to go home and straighten it out with Medicare. Ascencio makes the call for them and asks the patient to resolve the matter right away.

"By dialing the number and handing them the phone, we know for sure that they are letting Medicare know," she explains. "Only the patient can do that. And if something comes up in the conversation that the patient needs help with, we can become involved."

In some cases, Auto is still listed as the primary payer due to a car accident the patient had many years earlier. In other cases, the patient's spouse was still working when the patient became Medicare-eligible, and the spouse's coverage is still listed as the primary.

These Coordination of Benefits (COB) issues are the number one reason for claims denials at Lourdes. "A lot of that is between Medicare and Blue Cross, because they do a lot of finger pointing," says Ascencio. "Each payer says the other is the primary."

One problem is that Blue Cross requires that each subscriber complete a COB form once a year, asking about other coverage. If the patient has not completed the form, the claim will automatically be denied for COB by Blue Cross, even though Blue Cross is actually the patient's primary.

To stop these denials, staff members now ask every patient with Blue Cross to complete the form, and it's faxed to Blue Cross directly. Associates scan a copy of the form into the document management system, so if the billing office gets a denial for COB, they can just pull it up, print it, and mail it in with the claim.

The form needs to be signed by the subscriber, however, and that individual isn't always there to do so. "We make it as easy as we can. We give them an envelope to mail it in," Ascencio says.

Notation in system

Joan Braveman, corporate director of patient access, estimates that about 700 denials occurred in Lourdes' three emergency departments (EDs) in the previous six months, comprising 50% of all claims denials.

"Where we have the biggest issue is the ED: Sometimes you just don't have the time to be as thorough as needed," says Braveman.

If registrars know that an ED patient's Medicare is the primary, they put a note in the system stating, "This is definitely a Medicare primary. The patient's pneumonia has nothing to do with the broken arm he sustained in the auto accident."

The lead registrar in the ED reviews accounts to see if any denials involving Medicare can be avoided. "We see if there is any opportunity to clean up the account," says Braveman. "We have a bill hold of four days. So anything we do before then, other than causing rework on our part, is 'no harm, no foul.'"

Stop needless and costly write-offs

Hundreds of thousands in revenue at stake

A simple communication process has reduced writeoffs by hundreds of thousands of dollars at Milwaukee-based Wheaton Franciscan Healthcare.

"We had a huge problem with radiology procedures changing, but we have resolved the issue," says Kim Gehl, manager of patient access, central scheduling, and central precertification.

Patient access leaders worked with the radiology department and developed a communication tool. This form is one that the servicing department completes and faxes to the central precertification department. They do this step anytime the procedure changes from what was authorized.

"The department knows what was authorized, as that information is provided to the servicing department," Gehl explains." [The form is below. For assistance, contact customer service at [email protected] or (800) 688-2421.]

These steps are taken when a procedure changes from what originally was authorized:

1. The fax from the servicing department is received in central precertification.

"The form is faxed the same day the new procedure was done," she says. "This notification is a trigger to the precertification department to update or obtain a new authorization."

2. The precertification rep contacts the insurance company to obtain a new authorization for the new procedure or additional service.

3. The information is documented in the billing system.

Team effort needed

At Danbury (CT) Hospital, patient access associates strive to offer customers same-day scheduling if at all possible, reports patient access director Cindy Thomas Lowe, CHAM. This creates challenges in obtaining the necessary preauthorization, however.

"Most times, we are able to accommodate the need," Lowe says. "It takes a team. Some of the challenges are required test preparations, precertification in order to get paid for the testing, and then making sure demand can be met."

The team effort involves scheduling with a member of the department where the test will be performed, and financial clearance to verify benefits and review authorization needs. "Usually, a nurse from the physician's office is available for a quick peer-to-peer [consultation]," says Lowe.

The hospital has found that its freestanding facilities have the competitive edge on same-day testing.

"We are trying to meet the demand to so that physicians and patients look to us for their service," says Lowe. "Physicians usually drive this sort of testing. We need to market the ability to take care of their patients."

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].