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At Valley Health System in Ridgewood, NJ, patient access staff perform pre-registration up to 20 business days before most scheduled procedures, reports Maura Corvino, MSOL, RN, CEN, assistant vice president for emergency services and patient access.
"We make sure that the physician's intention matches what the validation is," says Corvino. "Four days before case day, we are really working closely on that group of people."
Certain procedures are mandated by insurers as "inpatient only," explains Corvino, but the physicians might not think the admission is necessary. When this situation happens, the physician is notified so he or she can write the appropriate orders well before case day, she explains.
The new process means that more OR procedures are starting on time, says Corvino. "More on-time starts for the physicians will probably open up ORs for a few more cases," she adds. "That has the potential to bring us some more revenue as well."
Many claims denials were occurring because authorizations weren't obtained upfront and were obtained only after the patient was in the hospital, explains Susan Sigler, supervisor of Valley Health System's patient access center. "That was a big driver of this change," Sigler says. "We had to go back and make the corrections and get the denials overturned."
This system meant a lot of manual work for the case management department that is no longer necessary, says Sigler. "In moving that work up to the front end, we expect to see a really significant drop in denials," she says. "By ensuring the right disposition for a given procedure, whether admit, observation, or discharge, everybody is on the same page with the insurance company."
More data needed
If the procedure code doesn't match the diagnosis code, says Sigler, registrars have to get more information from the physician.
"The physician is very knowledgeable about the plan of care and the patient's condition, but sometimes not so detailed when they give the diagnosis code," she says. "Sometimes it takes a little bit more data than what we have initially to get the authorization."
Previously, there wasn't time for this back and forth dialog, which meant that the case was delayed or the patients were left with a bill that they didn't anticipate, says Sigler. Corvino says, "Because this is medicine, a diagnosis code may change. If that's the case, we can go back and change it while the patient is still here, rather than getting that denial and going back for the rebill."
Sigler expects patients will be more satisfied with the new process. "If we are able to do all of this in a manner that streamlines things for the patient, hopefully that will be reflected in our hospital patient satisfaction scores," she says. "With new emphasis on the [Hospital Consumer Assessment of Healthcare Providers and Systems], that could impact how we are reimbursed going forward."