Denial initiative nets $2.5 million
Obtain much-needed revenue
I'm going to teach you some of the basics of billing and claims management." When Mary Calloe, director of patient access services at Cambridge (MA) Health Alliance, said this statement to members of her staff, they weren't too happy about it.
"I got some strange looks when staff thought they were going to become billers," she says. "I explained to them that I was going to show them how the work they did in patient access had a direct connection to the hospital's ability to get paid."
The patient access department's denial management initiative has obtained $2.5 million in additional net revenue annually for the last couple of years, reports Calloe. Staff received training on how to interpret data from payers, and a new claims management system was implemented.
"Denials that are attributed to patient access related areas are the lowest of all categories we track," says Calloe. "We have now come full circle. Staff can see a clear connection to their work and are concerned about getting every dollar."
Previously, the department didn't have good data as to the underlying reasons for claims denials, Calloe says.
"We went from having no data to working closely with our IT department and getting a tremendous amount of data," she says.
The reason for a denied claim could be something as simple as an invalid zip code or something more complex, she explains.
"It could be something that is very minute and not intuitive," she says. "It could be that a payer wants something done differently from every other payer."
Patients might change their insurance coverage or have multiple coverages. "That, in addition to new products, in- or out-of-network plans, and wide variations in out-of-pocket expenses due from the patient just keep adding to the everyday challenges," says Calloe.
Clinical expertise
"One of the biggest areas that we were losing money on was high-end imaging services that required a prior authorization," says Calloe. Due to more complex authorization requirements for these tests, it was determined that patient access needed an employee with a clinical background, she adds.
"We were able to support the need for a nurse/coder to help facilitate the information flow between the department and the insurance company," says Calloe. "With a change in the process and the additional skill set, we were able to reduce denials in this area by more than 50%."
Patient access leaders now attend meetings in clinical areas to obtain feedback on payer trends and patient experiences, she reports. "When you talk about it in terms of customer service, it gets providers thinking about the process differently," she says. "We never want a patient to get a bill inappropriately."
I'm going to teach you some of the basics of billing and claims management." When Mary Calloe, director of patient access services at Cambridge (MA) Health Alliance, said this statement to members of her staff, they weren't too happy about it.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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