Hospital leaders face a common challenge in managing claim denials based on problems with treatment authorizations, which often occur when there has been a deviation in the plan of care. To address such denials, clinical and operational teams are burdened with securing authorizations for the altered treatment plan prompted by changes in the patients’ health status.
All too often, approvals are not processed with the health plan because the treatment plan changes are not communicated effectively with the authorization teams. The screens on the existing overall management or operating system may register the charges for the claim, but the system fails to confirm the health plan authorization.
The result is that care is delivered, expense is incurred, and claims are denied, leading to write-offs for the hospital. Ultimately, documenting medical necessity to ensure payment removes the financial burden of claim denials caused by the documentation failure, but it doesn’t relieve the burden for staff of having to follow up on the authorization.
Case Example: Bon Secours Health System
In 2017, Bon Secours Health System, a not-for-profit Catholic health system headquartered in Marriottsville, Md., sought a revenue cycle management solution to effectively address these specific types of denials-related challenges. The overall goal of the initiative was to maintain Bon Secours’ clinical excellence while mitigating the financial impact of denials.
The health system’s care team and the revenue integrity team focus on charge compliance and charge-to-capture. They emphasize the importance of documenting that the hospital system is capturing the correct information and is confirming that they have submitted the information in accordance with Medicare standards. Commercial processes for authorizations and claims payment—a significant part of the health system’s business—are complicated compared with Medicare processes.
Bon Secours recognizes that hospital leaders must make effective charge capture a priority, ensuring that it reflects care delivery and that all procedures are captured. They also should make a full commitment to managing payment denials, with the goal of identifying every opportunity for preparing accurate claims that meet all health plan requirements.
Following internal trials with various enhancements of different workflows, and after conducting research with minimal positive results regarding claim denials, the Bon Secours team chose a software tool for denials management that could be deployed on site or hosted in the Cloud.
Identifying the Issues
Among the specific challenges regarding treatment authorizations that Bon Secours’ needed to address were issues arising in the health system’s Outpatient Infusion Center (OPIC), which provides treatments such as chemotherapy.
These issues were most confounding when there was a deviation in the plan of care necessitated by a change in the patient’s health status, which required clinical and operational teams to secure new authorizations for treatment. Too often, these approvals were not processed with the health plan for a variety of reasons, the most common being that the clinicians and providers were focused the plan of care with the patient and did not communicate the changes to the authorization team. The resulting denials led to costly appeal efforts and write-offs. For example, the billing system registered a revised drug regimen—for which an authorization was not obtained—as “change not known.”
Another cause for denials was failure to appropriately document medical necessity. CMS and commercial health plans are continually updating coverage requirements and needed documentation. The tool assisted the revenue cycle team in identifying accounts prior to billing and communicating directly with the provider.
Features Required for an Effective Solution
The Bon Secours revenue cycle leadership team sought an efficient revenue cycle management platform that could be overlaid upon existing systems to help them compare massive amounts of data across the health system’s enterprise; detect exceptions and problems; and guide interventions to improve efficiency and optimize financial, clinical, and operational performance.
The team determined that the selected platform’s analytics should be accessible at any time, day or night, and be capable of informing action and functioning as a permanent, protective “umbrella” that would make data comparable for auditing and reporting. Being able to continuously monitor processes through data would enable the team to detect issues as they occur and take immediate corrective action.
One of the most desired features for the platform was the ability to provide customizable, exception-based triggers that would identify deviations from norms and alert users, thereby helping them reduce errors and denials, improve efficiency and productivity, and meet compliance requirements. Bon Secours wanted a tool that could adapt to the circumstances under which which it would be used and work with existing tools.
OPIC presented an ideal area for a pilot of the new system because it had a finite number of users in a controlled environment and had proven problems with claims.
Chemotherapy, for example, is very closely monitored for patient reactions to treatment. Therefore, changes in clinical condition and its management are common. However, it is simply not clinically admissible to deny or delay a time-sensitive treatment to ensure health plan authorization.
Bon Secours’ leaders initially identified rules that governed authorizations for infusion treatments and directed that the tool initially be used for monitoring CPT charges in a pilot conducted in hospitals in Bon Secours’ Virginia market. The goal of the rules was to ensure all CPT charges had a proper authorization documented—for example, that it was necessary to determine at the date of service whether the authorization was still valid or had expired.
By triggering alarms when users deviated from the rules, the tool provided critical insights for diagnosing problems with the authorization process. The opportunity for corrective actions became so great that the hospital leaders quickly expanded the original rules, and the changes were readily accommodated.
The original rules expansion was the reflection of the initial results analysis: It involved making rule refinements such as changing users’ behavior by payer, ensuring Medicare was isolated (because authorization is not required); implementing thresholds to avoid triggering alarms for drugs that do not require an authorization; and creating new rules such as authorized number of services against current and new medical necessity validations.
The pilot was so successful—and the improvements realized so quickly—that the rest of the health system adopted the changes just after three months.
Preventive resources also were made available for charges authorizations management, including:
- Authorizations about to expire based on the authorization “to date” (authorization time window analysis)
- Authorization about to expire based upon number of approved services (authorized usage versus real usage)
As a result, the patient access team has a set of preventive dashboards that prompt them to proactively analyze accounts where authorizations for certain procedures are about to expire or about to be exceeded in terms of authorized usage. The tool ensured that the authorization team and clinicians were able to continue using the same processes they had always used, but with better results.
Implementation was based upon a risk score model, based on the following guidelines:
- An account is marked low risk if its authorization is up to date.
- An account is considered to be medium-risk if the authorization is set to expire within seven days of the last date of service, or if the number of services currently performed or is approaching the limit.
- An account deemed high risk if its authorization has expired or the authorized usage has been exceeded —a situation that triggers a prompt for staff to review the account.
At a staff level, medium-risk accounts receive the most attention because they can quickly spiral into major problems.
Achieving Clinical Excellence and Financial Viability
As a nurse, Bon Secours’ administrative clinician leader serves as the liaison among the clinical team, the patient, and the finance department. This role requires optimizing workflow and ensuring maximum payment without jeopardizing patient care.
The revenue cycle management tool allows Bon Secours to maintain excellent clinical care while prompting staff to secure the necessary authorizations. Because health plans require an increasing amount of documentation in order to pay claims, health systems need technology and processes to ensure those requirements are met. With slim margins, there is little room for error, and health system’s time, energy, and resources should go to patient care rather than payment efforts.
Results and ROI
Within six months of implementing the new tool, Bon Secours realized significant savings related to denials and write-offs, and the saving continue to accrue. In addition to a decrease in denials, back-end processes are now streamlined, relieving administrative burdens imposed on the clinical staff due to appeals.
Inadequate or missing documentation of medical necessity has been addressed. When these at-risk accounts are identified, the team reaches out to the physician for more in-depth documentation on the new medication regimen or for research articles that support the regimen. If the physician is unable to provide adequate documentation, he or she may consider changing the course of treatment or working with the patient to transition the charges to self-pay. The team also may work with the pharmacist to seek alternatives to prescribed medications, such as samples that the pharmaceutical company may provide free of charge.
Bon Secours continues to work to validate other areas of opportunity within the revenue cycle to apply technology toward improving processes, with the ongoing objective of mitigating revenue losses by identifying opportunities to eliminate problems early that can lead to denied payment from the payers.