Scavengerhunt through the Denials process

1. Scavengerhuntthrough the Denials process By: Cathy Cover, MHA; RHIT Diane Castro, RN, QIO

2. Objectives • Process of Review • Appeal Process • Correct Documentation • Steps to reduce denials • Successful recovery

3. Process Review of where we were • Concentration on the authorizations and making correct plan code • Sending medical records and defending medical necessity for LOS, LOC • Appeal dollars were easy to win with supporting documentation

4. What is happening now… • Repeated denials within hospital systems occur frequently for the same patient and typically happen for several reasons. • Out-of-date demographic data • May not be informed of the original denial • Decentralized outpatient areas • Expected to understand fully the various third party payment rules, yet all too often they lack sufficient training to fulfill this expectation.

5. Process Review Continued • Concentration on what codes did we use to bill • What insurance requires what medical records • What days to approve and did the physician write supporting documentation

6. Process • Pre-register all scheduled patients 3 days in advance • Obtain complete and accurate patient information • Demographic • Insurance • Medical • Notify patient of co-pay due and collect • Investigate other potential coverage sources

7. Appeal Process What the Denials Team reviews when researching an account prior to appeal • Did registration obtain proper insurance information? • Did registration work with physician office for authorization? • Is the documentation recorded for future? In the system? Scanned? • Did they provide specific codes to the insurance companies? • What are the codes used for pre-auth a procedure • Do we have supporting documentation from the attending physician and the primary care physician • Is there evidence that patient had any conservative treatment prior to any surgical procedure?

8. Correct documentation • Prior to scheduling: • Working with scheduling and nursing staff for proper documentation • Obtaining authorizations at least one week out prior to allow for changes

9. FCSO vs. RAC

10. MEDICARE FIRST COAST REVIEW • Payment review of 15 DRGs listed • Review of Medical Necessity and Admission Status • Deny hospital payment if criteria is not met and not documented in medical records • Jan 1, 2012 - will deny physician services as well • Physician will be paid, but then FCSO will do post payment review and take payment back.

11. Initial FCSO Inpatient Prepayment DRGs DRG Descriptor 226 Cardiac Defibrillator Implant w/o Cardiac Cath w MCC 227 Cardiac Defibrillator Implant w/o Cardiac Cath w/o MCC 242 Permanent Cardiac Pacemaker Implant w/ MCC 243 Permanent Cardiac Pacemaker Implant w/ CC 244 Permanent Cardiac Pacemaker Implant w/o CC or MCC 245 AICD Generator Procedures 247 Percutaneous Cardiovascular Procedure w/ Drug Eluding Stent w/o MCC 251 Percutaneous Cardiovascular Procedure w/o Coronary Artery Stent w/o MCC 253 Other Vascular Procedures w/ CC 264 Other Circulatory System OR Procedures 287 Circulatory Disorders Except AMI w/ Cardiac Cath w/o MCC 458 Spinal Fusion exc. Cerv w/ spinal curve, malig., or 9+ fusions w/o CC 460 Spinal Fusion Except Cervical w/o MCC 470 Major Joint Replacement or Reattachment of Lower Extremity w/o MCC 490 Back and Neck Procedures ex. Spinal fusion w/ CC/MCC or disc.

12. FCSO additional requests DRG Descriptor 153 Otitis media and URI w/o MCC 328 stomach, espohageal and duodenal proc w/o CC or MCC 357 Other digestive system OR procedures with CC 455 Combined ant/post spinal fusion w/o CC or MCC 473 Cervical spine fusion w/o CC/MCC 517 Other musculoskeletal system & connective tissue OR procedure w/o CC or MCC

13. Steps to reduce denials • Staff areas appropriately • Adequately train all staff • Schedule as many patients as possible • Pre-register as many patients as possible • Pre-verify as many patients as possible • Audit registrations • Collect, collect, collect!!

14. Steps to reduce denials • Multi-discipline meetings – should consist of: • Admitting team • ED registration team • Authorization unit • Case management • Denials management • Managed care • Ancillary departments – as needed • Radiology • Cardiac – cath lab, cardiac rehab • Therapies – PT, OT, ST

15. Steps to reduce denials • Tracking system • Develop a database for tracking and trending • Develop standard reports • Drill down to line item

16. Steps to reduce denials • Reporting • Monitor standard reports on regular basis • Identify new trends – this will allow the issue to be resolved and addressed quickly before it has a huge impact on your AR

17. Successful Recovery of Dollars • TEAM WORK • STRIVE FOR THE GOLD!!!!!!

18. QUESTIONS