Fix mistakes before the payer denies the claim
Fix mistakes before the payer denies the claim
Do corrections on the front end
How many claims denials have occurred at your hospital because of mistakes that could have been easily corrected? Unless this information is put into the hands of registration staff in a timely way, errors will at best, get further along in the process. At worst, this will result in a denied claim.
The patient access department at Saint John's Health System in Anderson, IL, has no automated quality assurance (QA) system. "So a very time-consuming manual QA is being done on insurance errors. This allows for no extra time to even think about how this affects staff performance," says Suzan Lennen, CHAM, manager of patient access.
Staff are the ones who correct their own errors, if time permits. "Sometimes the changes need to be made immediately, so all we can do is show them the errors they made," says Lennen.
At Advocate Illinois Masonic Medical Center in Chicago, the patient access department recently implemented an electronic tool for registration quality assurance. One important feature is an electronic work list, used by staff on a daily basis to correct their errors.
"In the past, auditing and making corrections was someone else's job," says Michael F. Sciarabba, MPH, CHAM, director of patient access services. "Now, this integrated tool will actually alert staff to their own errors."
One to three days after the registration is done, staff go into the system to check their work. They self-correct their errors based on the alerts they receive. However, compliance with getting busy staff to diligently check their work list is somewhat of a challenge.
"Still, we have seen an error reduction rate of 14% by most associates," says Sciarabba. "This is based on averages of 350 total registrations per associate per month, with 50 errors per month that were corrected. If this is multiplied by numerous associates, the reduction in error rate could be transformational for the revenue cycle!"
QA in hands of access
"In the past, staff have always asked me for regular and timely feedback on their errors. I've always struggled with giving them that information," says Sciarabba. "This puts quality in the hands of the associates, instead of the hands of someone else."
Previously, auditing was done manually. "It was someone else's responsibility. This new process actually forces the person to go back and correct their work," says Sciarabba. "It has really transformed the way we look at quality. Ideally, over time you are getting less and less errors."
The process allows staff to catch, and correct, Medicare and Medicaid plans that should have been entered as an HMO replacement. "Not only is this an expensive error for the organization, it is a compliance issue as well," notes Sciarabba. "Now, an associate has an additional opportunity to correct the error they have made. This prevents a denial and assures that Medicare and Medicaid are not being billed inappropriately."
Manual auditing usually meant the registrar leaving a hard copy of his or her work for someone else to review. The auditor would frequently get behind, with so many accounts to review that key components of the registration would get missed.
"After completing the audit, they would have to schedule time to review with the associate," says Sciarabba. "By the time all this was completed, it could be a week later. The associate could have made the error continuously over that period."
This type of auditing was untimely, manual, and costly. With the new process, quality specialists and trainers spend their time on key areas for improvement while the associates ensure their own quality. "It allows them to take action," says Sciarabba. "People don't want to make errors. They want to be accurate, but giving them the tools to do that is where we always struggled. This brings a whole other level of professionalism to their work."
While patient access uses one system to make corrections, patient accounts uses billing rejections to make corrections and re-bill. "Patient access and patient accounts are partnering to streamline this process," says Sciarabba. "The idea is to prevent billing rejections from happening, with more clean claims going out electronically on a daily basis."
A common problem is that information is all entered correctly, but when the claim goes to billing, it turns out that the payer's information isn't updated. The system gives staff alerts from payers as well. "Sometimes this is an update we didn't know about. The staff ask us about it because they get the alert and don't know what to do with it," says Sciarabba.
At times, though, claims denials occur because of things completely beyond the control of access. "Everything can be in order from an administrative perspective, but if the clinicals aren't called in by case management, you are left with a denial for precertification," says Sciarabba. "We see that a lot."
Sciarabba recommends separating out administrative denials from denials that are clinically related. "Sometimes these are grouped in together, but separating the two out is really important for managers to do," he says. "Otherwise, you could appear to be doing worse than you actually are."
Track accuracy
Debbie Bartel, registration coordinator for patient access at St. Elizabeth Hospital in Appleton, WI, says, "The old adage, 'garbage in, garbage out' truly has a distinct meaning where upfront errors are concerned.
"Registrars have a lot on their shoulders to get accurate and complete demographic and insurance data on patients," says Bartel. "The bulk of registration accuracy does rely on registrars to be accurate and efficient with entering the data."
The department stresses accurate spelling of the patient's diagnosis, accurate typing of correct policy and group numbers for insurance data, and making sure the correct subscriber is listed on the insurance.
Registrars get six weeks of training, along with monthly department meetings in which they review common registration errors. "We show screen shots of the errors we are seeing," says Bartel. "We also have to ensure we are typing in the correct address for the patient, so bills and follow-up are sent to the correct patient address."
One-on-one training is done with registrars with continuous errors, and registrars are given spelling quizzes on medical terminology.
An online eligibility system verifies insurance coverage. "This tells us when there is a discrepancy with the policy or ID number for insurance," says Bartel. "Registrars are able to correct things during the registration stage, before a bill goes out."
This process is used to track the accuracy of established access employees:
A minimum of 10% of one month's work is reviewed for each employee, a minimum of three times per 12-month period.
Failure to meet a 95% accuracy rate will result in 100% review, until the employee attains and maintains the standard of 95% accuracy for three audits.
Upon failure to attain and/or maintain the 95% quality standard, the reviewer will inform the department manager or director. The employee will be subject to 100% review of work until maintaining 95% accuracy for five consecutive work days.
"Using your tracking tool congruently with your registration process should show you where the weakness lies, where denials are concerned," says Bartel. "By outlining and drilling down these errors for each registrar, you can take this data and incorporate your findings in their performance evaluations for future improvement."
[For more information, contact:
Debbie Bartel, Registration Coordinator/Patient Access, St. Elizabeth Hospital, Appleton, WI. Phone: (920) 831-1332. E-mail: [email protected].
Suzan Lennen, CHAM, Manager, Patient Access, Saint John's Health System, Anderson, IN. Phone: (765) 646-8136. E-mail: [email protected].
Michael F. Sciarabba, MPH, CHAM, Director, Patient Access Services, Advocate Illinois Masonic Medical Center, Chicago, IL. Phone: (773) 296-5071. E-mail: [email protected].]
How many claims denials have occurred at your hospital because of mistakes that could have been easily corrected? Unless this information is put into the hands of registration staff in a timely way, errors will at best, get further along in the process. At worst, this will result in a denied claim.Subscribe Now for Access
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