Collaborate to stop 'no authorization' denials
Review as a team
Reasons for claims denials often can be traced back to factors beyond patient access, such lack of medical necessity, lack of clinical documentation, or a physician not participating with a plan. This is why "patient access cannot work as a silo in reviewing claim denials," says Carol Triggs, MS, director of patient access at St. Joseph's Hospital Health Center in Syracuse, NY.
Timely review of claim denials is undeniably necessary, but Triggs says that working with other areas of the hospital is equally important. This means the involvement of case management, managed care contracting, patient accounting, patient access, and medical records.
At St. Joseph's, these five areas joined forces in a Six Sigma project. The goal was to create a process to reduce denials due to no authorization. One common example involved the scenario of a patient registered as an observation or one-day ambulatory surgery patient, who is converted to an inpatient as a result of a physician's order.
If the change from outpatient to inpatient status is not communicated to patient access, an authorization for the inpatient visit will not be secured. The insurance company may deny payment, or a payment penalty may be incurred. In this situation, "the perception was that the denial for no authorization rested solely on patient access," says Triggs.
Denials for no authorization are now reviewed by a team. "Our project scope was to understand the reasons for the no authorization denials, and review our existing controls and the process in place to review and respond to these denials," says Triggs. "Our primary focus was to improve the quality of the data for 'no auth' adjustments, and enhance the appeals process."
After extensive data analysis, staff developed new "no authorization" adjustment codes to reflect the true reason for the denial. The new codes segmented the reason for the denial into these specific categories: visit type change, failure to notify, medical necessity, managed care issue, and MD issue.
"We were then able to quantify accurately the reasons for the 'no authorization' denials on a monthly basis," says Triggs. This is reported back to the individual service area directors via a monthly scorecard, which is also reviewed at monthly revenue cycle meetings.
"In addition, an appeals process was developed and implemented to assure a timely appeal process for the denials," says Triggs.
[For more information, contact:
Carol Triggs, MS, Director of Patient Access, St. Joseph's Hospital Health Center, Syracuse, NY. Phone: (315) 448-5379. E-mail: [email protected].]
Reasons for claims denials often can be traced back to factors beyond patient access, such lack of medical necessity, lack of clinical documentation, or a physician not participating with a plan. This is why "patient access cannot work as a silo in reviewing claim denials," says Carol Triggs, MS, director of patient access at St. Joseph's Hospital Health Center in Syracuse, NY.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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