Revamp process for admission notification
Revamp process for admission notification
Denials down to 0.08% from .68%
If a patient is admitted on a holiday or after normal business hours and registrars are unable to notify the payer until the next business day, the claim could be denied for late notification, warns Jeanette Foulk, director of patient access at Methodist Charlton Medical Center in Dallas.
“Our 2012 fiscal year denial rate due to authorizations/notification denials is currently at 0.08%, down from .68% in fiscal year 2010. This is a significant amount of money,” she says. These steps are taken by patient access staff to ensure timely notification of admissions:
1. Every day, a registration representative runs a census from the hospital’s registration system.
“This logs all of the previous day admissions and the insurances that were listed at time of registration,” says Foulk.
2. The reports and demographic sheets for those patients are separated and delivered to financial counselors who handle that insurance carrier.
“We routinely have high volumes. This makes it unrealistic for the registration rep to also try to obtain an authorization at point of registration,” Foulk explains. “Each financial counselor will work the report, noting completion of each patient account.”
3. Throughout the day, the financial counselor runs a same-day admission report for payers requiring same-day notification.
“We have seen a major increase in our Medicaid HMOs — which is a significant portion of our patient population — requiring same-day notification, along with several commercial payers,” reports Foulk.
The same-day report was added because the department was seeing a surge in denials for same-day admissions due to lack of notification, says Foulk. The report is “essentially an hour-by-hour census,” she says.
For patients admitted from the emergency department, staff often have trouble obtaining accurate insurance information at the time of admission, which means the patient’s coverage can’t be verified as active until later on, says Foulk.
“We may rely on a family member to provide us what is needed, which may not be within 24 hours,” she says. (See related story on new authorization requirements for procedures, above right.)
Sources
For more information on notifying payers of admission, contact:
• Jeanette Foulk, Director of Patient Access, Methodist Charlton Medical Center, Dallas. Phone: (214) 947-7560. Fax: (214) 947-7566. Email: [email protected].
Multiple authorizations for single procedures
While many payers required authorization for injectable procedures for some time, they’re now adding a new requirement.
“We are now receiving denials for failing to obtain authorization for the medication in those injections. This is something we had not seen previously,” reports Jeanette Foulk, director of patient access at Methodist Charlton Medical Center in Dallas.
Currently, patient access staff are seeing authorization requirements for chemotherapy injections that weren’t required previously, which leads to high-dollar denials, says Foulk.
“We are now informing the referring physician’s office to request a medication authorization code when obtaining the authorization for those procedures,” she says.
Get clinical info in hands of payers
Resolve communication breakdowns
Payers are asking for much more clinical information before giving authorizations for services, reports Margie Mukite, director of patient access at Advocate Condell Medical Center in Libertyville, IL.
When patients are admitted, have surgery or high-dollar diagnostic tests such as magnetic resonance imaging, CT scans, nuclear medicine perfusion scanning, positron emission tomography (PET) scans, or chemotherapy infusions, payers want to know the patient’s medical history, including prior treatment plans and clear documentation as to why the medical services are required, says Mukite.
“Payers are requesting CPT and ICD-9 codes,” she says. “Aside from the clinical information, payers also are requesting office notes from the past 12 months, and health and physical history.”
Payers are asking for CPT codes, diagnosis codes, and clinical information to support the medical necessity of the patient’s scheduled services, says Sharon Mumgaard, insurance verification coordinator at St. Elizabeth Regional Medical Center in Lincoln, NE. “This information is required to pre-certify mostly high-tech radiology services and surgeries,” she says. “However, we have recognized a rise in insurance pre-certification requirements for other diagnostic tests such as nuclear medicine and sleep studies.”
Push-back from MDs
Because clinical information must be provided by the physician’s office, close communication with physicians and office staff becomes important in order to get this information submitted prior to the patient’s scheduled visit, says Mukite.
With patient access acting as the “middleman” between payers and physician offices, says Mukite, “ultimately, it comes down to real-time communication between the offices, with follow-through by patient access to confirm that the authorization is in place.”
Unfortunately, patient access staff members often encounter “push-back” from staff at physician’s offices who don’t feel providing clinical information to payers is their responsibility, adds Mukite. “They feel that is the responsibility of the hospital. However, we do not have the patients’ clinical information,” she says. “Higher-ups should be involved immediately, in order to resolve the communication breakdown.”
Financial penalties common
Failure to obtain the required pre-certification almost always results in a financial penalty to the hospital or the patient and, often, the complete denial of the claim, says Mumgaard.
“There are times when the physician’s offices do not have the ordering physician’s dictation available to them so that they can provide the clinical information needed, especially if the services are ordered for the very near future,” she adds.
Mumgaard says that the most helpful change in this process would be to have the physician’s offices provide more insurance information and CPT and diagnostic codes at the time of scheduling. However, Mumgaard has found the physician’s offices to be resistant to making this change, even though more time might be spent in the long run to coordinate this information.
“All healthcare providers are experiencing the need to do more with less,” she says. “A closely monitored pre-certification process is definitely a team effort between the facility and the physician office.”
Source
For more information on clinical information required by payers, contact:
• Margie Mukite, Director of Patient Access, Advocate Condell Medical Center, Libertyville, IL. Phone: (847) 990-6070. E-mail: [email protected].
• Sharon Mumgaard, Insurance Verification Coordinator, St. Elizabeth Regional Medical Center, Lincoln, NE. Phone: (402) 219-8950. Fax: (402) 219-8974. Email: [email protected].
If a patient is admitted on a holiday or after normal business hours and registrars are unable to notify the payer until the next business day, the claim could be denied for late notification, warns Jeanette Foulk, director of patient access at Methodist Charlton Medical Center in Dallas.Subscribe Now for Access
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