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Use online resources for better registration accuracy
At Hackensack (NJ) University Medical Center, patient access staff are taking steps to improve precertifications and registration accuracy by obtaining information electronically.
"Our goal is to use online means to verify insurance, benefits, and obtain precerts and authorization," says Anne Goodwill Pritchett, vice president of patient financial services.
Goals are established for each hospital or clinical service. For example, in 2008, the goal was to reduce precertification and eligibility-related denials by 20% by Dec. 31, 2008. This reduction was based on the cumulative amount as of Dec. 31, 2007.
"When patients schedule elective services online, during that process, not only do we capture the services that the patient is coming here for, but also the name and basic demographic information, including insurance and policy number," says Goodwill. From that scheduling system, staff are then able to pre-register the patient and do a financial clearance. Insurance and benefits are verified electronically, using an online insurance verification process.
"Staff also have online access to most major payers to determine eligibility and benefits, says Goodwill Pritchett. In most instances, staff can key in the payer's name and patient's policy number and, within seconds, will get a response from the payer indicating that the insurance is active and what the copay or deductible are."
At that point, staff also can determine if that service requires an authorization. "We also can obtain the precertificiation of the authorization for many of the services online. For example, Aetna and Horizon Blue Cross and other payers have outsourced their precertification capabilities, and use a third party to provide precertification, and staff can key in the CPT code to obtain these authorizations.
"Before, you had to call to get that information. Now you can get it online," says Goodwill Pritchett. "The online process has significantly improved pre-certs turn around time."
Denials are tracked
Implementing the electronic remittance advice for most major payers has significantly improved the department's ability to track denials electronically by payer. "We are able to identify and resolve trends much sooner," says Goodwill Pritchett.
All new patient access employees attend a formal four-day training program before getting a system sign-on. The training covers how to utilize the system, regulatory and payers guidelines, and hands-on system training. "They get a lot of practice time in that four-day period, and after that, they go onto the floor," says Goodwill Pritchett.
Ongoing quality assurance is done, with performance analysts routinely checking the quality of work done by staff.
"Every day, we post our denials, sorted by payer and category of hospital service, so we can immediately tell if we have issues," says Goodwill Pritchett. "We look at how many accounts are denied because somebody did not obtain authorization for an MRI or imaging, for example. These sometimes are denied in error - the payer may have made a mistake."
This can be determined easily because the precertification data is on the billing record. "So it's very easy to determine who is responsible for the denial. If it is our error, and it happens that an error is made here and there, fine. But if it happens routinely by particular employees, we retrain them if necessary, and if continues, we follow the disciplinary process. We have very tight controls over denials because that impacts the bottom line."
Staff take great pains to keep up with the changing requirements of payers. "For Medicare, we go online several times a month, just to make sure we see any regulatory changes," says Goodwill Pritchett. If there are regulatory changes, these are printed out and reviewed.
On a monthly basis, Goodwill Pritchett reviews all of the new regulations, not just those that affect the billing department directly, but also anything that affects the organization. "At the end of the day, much of it will impact billing," she explains. "For example, if there is a change in the CPT code, where the payer used to allow three codes but now they allow only one, we then bring in the clinical service that is involved to be sure they are aware of it and that their charge screens have been updated."
Any changes made by managed care payers are obtained through the department's managed care director. In addition, the department brings in provider relations representatives of the payers onsite at least twice a year, to conduct training sessions for the registration staff and billing staff. "This is a chance for them to clarify any changes that have occurred and clear up any misinterpretations that our staff may have," says Goodwill Pritchett. "It is really very helpful."
The department also has its own internal trainers. If something needs to be put in a policy format, it is disseminated in an educational bulletin, such as major changes for a unique payer plan or product line. "If it's something very major, we will also have formal face-to-face training sessions," says Goodwill Pritchett. "This is a dynamic environment that is changing constantly. We recognize that in order to have an effective registration and billing staff, people have to be educated."
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