The Role of Patient Access
in Denial Prevention and
Intervention
Presented by: Sarah Mendiola, Esq.
Associate Attorney
Fotheringill & Wade, LLC
Discussion Objectives

Patient Access Issues and Goals.

The Role of Patient Access in the prevention of Lack of
Authorization denials.

Best Practice concepts for denial prevention.

What to do if a claim is denied.
Patient Access Goals

Increase rate of clean claims billed;

Reduce denials and administrative burden of rebilling
claims/appeals;

Increase collection of patient responsibility; and

Identify services that might result in zero payment prior
to being rendered.
Patient Access Challenges
Cause
Effect

Accurate patient data not captured
prior to the visit.

Likelihood of clean claim
decreases.

Staff members uncomfortable
communicating patient financial
obligation.

Reduced opportunity to collect full
amount owed by patient.

Longer patient wait times,
decreased patient satisfaction.

Missed revenue opportunities,
team not operating at best
practice level.


Processes are manual, rather than
automated.
Inconsistent policies and
procedures for registration.
Patient Access Solutions

Leadership and employee education on the importance of accurate
data collection and insurer requirements.

Consistent processes across all patient access areas for insurance
verification, determination of patient financial responsibilities and
point of service collections

Push for insurers to standardize practices and make requirements
clear/easily accessible.

Robust and automated reporting to facilitate identification of
opportunities for improvement.

Know how to spot denials so that opportunities for appeal are not lost!
Administrative Denials – Some Top Reasons

The claim was filed Late

The Service was Already Rendered

The Insurance Company Lost the
Claim, and then the Claim Expired

The Patient has an Out-of-State
Insurance Plan

Lack of Preauthorization/
Authorization

The Patient Lost His or Her Insurance
Coverage

The Patient Didn’t acquire a Referral
from a Physician

The Patient was Late to pay their
COBRA

You Ran Out of Authorized Sessions


The Authorization Expired
Claim sent to the Wrong Managing
Company

The Patient Changed His or Her
Insurance Plan

The Provider doesn’t participate with
the Insurance Company

The Patients' Out-of-network Benefits
Differ from In-network Benefits

Services Were Rendered at the Wrong
Location
According to a 2012 study completed by the AMA,
“The current prior authorization process is
extremely burdensome.”
The AMA’s report had the following findings:

Hassle factors related to the prior authorization requirements need to be
eliminated.

Preference for an automated prior authorization process.

Vague prior authorization requirements.

Long wait times with prior authorization requests.

Difficulty obtaining approval of prior authorization requests.

20 percent of first-time prior authorization requests are rejected by the
payers.

Physician practices need to appeal 80 percent of payer rejections of first-time
prior authorization requests.
Electronic Prior Authorization Practices
According to the AMA, handling your prior authorizations electronically can:

Speed up health insurer response.

Minimize time and resources devoted to manual processes, such as waiting on
hold and compiling faxes to payers.

Free up time for revenue-enhancing functions such as ensuring correct
payment.

Reduce transaction costs by over 80%.

Provide a paper trail to appeal claims that are subsequently denied.
Verify authorization prior to performing
services!

Is authorization needed for this particular service under this patient’s plan?

Check provider website/portal and/or call to verify.
If authorization was obtained:

Does it cover this particular service?

Is it for this date?

Is it still valid?

Has it been used already?
Lack of Authorization denials can come
in many different forms!
Auth Obtained/Erroneously denied
Scheduled Admit/Hospital failed to contact payer/obtain auth
Additional days requested/auth approved for lower level of care
Additional days requested/auth refused
Additional days not requested/stay exceeded auth
Auth not obtained but not required
Example of a Denial #1-Hidden Denial?
What does this really mean?
“Claim/service denied because the procedure/treatment is
deemed experimental/investigational by the payer”
The service must have been experimental, right?
This patient was admitted through the
ED and had an appendectomy.

Authorization was requested at the time of admission and was
granted.

The authorization was later denied, after clinical information was
submitted. The plan indicated that the patient could have been
treated at a lower level of care.

This was not an experimental service!
Best Practice Denial Management
Maximize Opportunities with Appeal Team
Intervention/Appeal Track
Prevention Track
Purpose:
To prevent retraction or obtain full
payment
Purpose:
To prevent future denials & ensure
compliance.
Methodology:
To pursue all appeal levels until
payment received or appeal and
dispute resolution procedure
exhausted.
Methodology:
Provide appropriate feedback to
Hospital staff

Track all denials by Physician and
Coder

Educate & respond according to data

Monitor & Measure Response
If I Knew Then What I Know Now…

The information that is obtained during the admitting
process is crucial to prevent and fight denials!

Almost all technical denials can be challenged:




Facts
State and federal laws
Contract provisions
Registration and Admitting staff should have access to key
contract provisions and laws:


Prevention of denials
Obtain critical facts
Insurance Verification Process

Just asking the right questions can prevent denials.


Verify eligibility and plan type and elicit information that is not
routinely provided:

Specific policy exclusions

Pre-existing conditions
Opportunity to correct potential benefit problems:

Early registration

Lapses in coverage during admission/patient involvement
Documentation is the key to
effectively preventing and fighting
denials.
Commercial vs. Medicare
Less work on the front end?


Still need to verify benefits!

Does the patient have Part A and/or Part B benefits?

Confirm the patient has not enrolled in Part C.

Hospice election?
No authorization needed for Medicare UNLESS Medicare Advantage Plan.

Requirements are plan specific.

Contracted vs. Non-Contracted
What documentation will be needed for this service?
If the patient is being pre-registered, can we tell them what to bring with
them?
Example of a Denial #2-Hidden denial?
What does this mean?
Remit Date 11/14/13
MA02
Claim Level CO A1-Claim denied charges.
MA02 Alert: If you do not agree with this determination, you have the
right to appeal.
Example of a Denial #2
Could this have been prevented?

The patient was admitted for a scheduled, elective Total Knee Replacement.

DRG 470 has consistently been targeted for pre-payment review.

Medicare requires that certain documentation be present in the record to
show that the procedure was medically necessary.

If the pre-operative documentation to show that the surgery was reasonable
and necessary is not present, the entire hospital stay may be denied.

MLN Matters Number SE1236-Documenting Medical Necessity for Major Joint
Replacement (Hip and Knee).
Example of a Denial #2
How could this have been prevented?


Best practices would involve coordination between the orthopedic surgeon’s
office and the provider so that the documentation is provided at the time of
registration.

Checklist of documentation requirements.

Packet must be submitted at the time of registration.
Notify the patient during pre-registration that they can/should bring any and
all documentation related to the procedure when they arrive.

Major joint surgery is often the last resort and the patient may have been
receiving various treatments over an extended period of time.
Example of a Denial #3
Could this denial have been prevented?
“These are non-covered services because this is not deemed a “medical
necessity by the payer.”
Example of a Denial #3
Could this denial have been prevented?

CPT Code 93880: Duplex scan of extracranial arteries; complete bilateral
study.

Novitas Solutions LCD L27504 explains the coverage criteria for Non-Invasive
Cerebrovascular Arterial Studies.

The patient was pre-registered for the outpatient diagnostic study.

Pre-procedure documentation from the referring physician to explain the
rationale for the test could have aided in ensuring that a clean claim was
billed and preventing the denial.
Example of a Denial #4
Could this denial have been prevented?
“Payment adjusted because the payer deems the information
submitted does not support this many/frequency of services.”
Example of a Denial #4
Could this denial have been prevented?

CPT Code 23472: Total Shoulder Arthroplasty

This was an Inpatient-Only Procedure billed on an outpatient claim.

This was an elective, scheduled procedure.

The patient was pre-registered for the surgery.

The facility could have an electronic “hard stop” instituted for certain
surgical codes that are on the inpatient-only list. This would trigger the
patient access department to register the patient as an inpatient.
How can we argue this denial?
What if you think you’ve done
everything right?
And the claim is still denied?
Appeals should include:

Documentation of telephone conversations:

Name, phone #, and department of the person providing benefits and/or
authorization.

Whether the entire admission was authorized and any concurrent review
(and proof) that it was provided.

Copy of written authorization.

Applicable contract terms.

Applicable state law.
Important Contract Provisions



Authorization/Notification requirements? Are they explicitly in the contract,
or is the provider manual controlling?

Under what circumstances is authorization required?

Timeframes?

Authorization number v. tracking number?

Referrals?

Updates to provider administrative guidelines?
Concurrent review requirements?

How often?

When does it start?
Verification of benefits requirements?
Real Contract Provisions!
“In the event that the lack of authorization can reasonably be shown
to have resulted from an action or inaction by Hospital, and Insurer
determines the services to be Medically Necessary, than Insurer shall
reimburse Hospital for all Medically Necessary Covered Services
rendered to the Member.”
“Notwithstanding anything to the contrary herein, Insurer shall not
deny or reduce payment for any Medically Necessary Covered
Services based on Hospital’s failure to comply with any
administrative or notification requirements as set forth in this
Agreement and/or the Provider Manual insofar as such services
would have been authorized as Medically Necessary if the
notification had been provided in the appropriate time.”
There are federal and state laws on the
following denial management topics:





Authorization
 Modification of authorization,
delivery/newborn,
emergency services
Claims submission
 Minimum time frames
Prompt payment
 Definition of clean claim,
payment time frames,
interest penalty
Misverification of benefits
Internal/External Appeals
•
•
•
•
•
•
•
•
•
•
Retroactive denials/Retractions
Notice prejudice
Lien laws
• Workers compensation, Third
Party Liability
Pre-existing conditions
Emergency Services
• State law definition, EMTALA
Continuation of Benefits
ERISA
Coordination of benefits
Automatic newborn coverage
Experimental treatment
Maryland Insurance Code
Title 15-Health Insurance
Just a few Maryland Laws regarding health insurance issues that may
come in handy:

Subtitle 4. Eligibility for Coverage; Continuation and Conversion of
Policies

Subtitle 6. Required Reimbursement of Institutions.

Subtitle 10. Claims and Utilization Review.


§ 15-1005-Prompt payment of claims.

§ 15-1006-Notice of reason for claim denial.
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
Maryland Insurance Code and Prior
Authorization!
§ 15-1009 (b) Reimbursement for preauthorized care - If a health care service for a patient has
been preauthorized or approved by a carrier or the carrier's private review agent, the carrier
may not deny reimbursement to a health care provider for the preauthorized or approved
service delivered to that patient unless:
(1) the information submitted to the carrier regarding the service to be delivered to the
patient was fraudulent or intentionally misrepresentative;
(2) critical information requested by the carrier regarding the service to be delivered to the
patient was omitted such that the carrier's determination would have been different had it
known the critical information;
(3) a planned course of treatment for the patient that was approved by the carrier was not
substantially followed by the health care provider; or
(4) on the date the preauthorized or approved service was delivered:
(i) the patient was not covered by the carrier;
(ii) the carrier maintained an automated eligibility verification system that was
available to the contracting provider by telephone or via the Internet; and
(iii) according to the verification system, the patient was not covered by the carrier.
Legal theories that may also be useful:

Misrepresentation

Detrimental reliance
“But for” or without the affirmative action on the part of
the insurer, the provider would not have provided the
medically necessary services.
Example 1
“Our Hospital” rendered medically necessary services to
John Doe from 7/1/13 – 8/22/13. Authorization was
obtained. On 9/30/13, the hospital timely submitted a claim
with total charges of $150,687.20 to It’s all about You
Insurance.
On 11/28/13, It’s all about You Insurance denied the claim
on the basis that John Doe was not eligible for benefits
during the date of service.
What is our best argument?

Benefits/eligibility was verified.
 Name, phone#, and department of the representative
that verified benefits, or a printout of the benefits
from the plan’s website.
 The benefits that were quoted.
 The effective date of the patient’s policy.
 Any policy limitations on payment.

State Law or Legal Theories


Detrimental Reliance
Any applicable contract terms.
Example 2
St. Elsewhere Hospital rendered medically necessary
services to Jane Doe from 11/15/13 – 11/16/13. A claim is
timely submitted to ABC Insurance on 12/01/13. On
2/28/14, ABC denied the claim for lack of
authorization/notification.
The hospital’s contract with ABC does not address preauthorization of services or notification requirements for
admissions.
What is our best argument?

ABC provided authorization.
 Provide documentation of any telephone conversations
or a copy of the electronic auth.
 Include
name, phone #, and department of person
providing auth.

State Law
 MD Law requires that if the services are authorized,
absent certain factors, the plan may not deny
reimbursement.

Any applicable contract terms.
In summary: The Patient Access Department
is the key to an optimal revenue stream.



Ensure accurate data gathering at the time of registration.

Plan information-eligibility, coverage and benefit limitations.

Authorization-active, valid auth for the services ordered.

Thorough documentation will help with the appeals process.
Decrease the incidences of denials by effective pre-screening.

Identify services that may be non-covered prior to them being rendered.

Identify services that require additional documentation development.
Increase the rate of clean claims.
The best defense is a good offense.
A successful patient access process will
ensure that the facility has the funding it needs
to carry out
high quality clinical care.
Disclaimer:
Please Note
The information conveyed in this presentation is for general educational
purposes and is not legal advice. The application and impact of laws can
vary widely, based on the specific facts involved. Given the constantly
changing nature of state and federal laws, there may be omissions or
inaccuracies in the information you receive during this program.
Accordingly, any information is provided with the understanding that the
presenter is not rendering legal, accounting, or other professional advice
and services. As such, any information obtained in this presentation
should not be used as a substitute for consultation with legal counsel or
other professional advisors specifically retained for that purpose. While
Fotheringill & Wade, LLC has made every attempt to ensure that the
information contained in these materials is generally useful for
educational purposes, Fotheringill & Wade, LLC and its agents &
employees are not responsible for any errors or omissions or for the
results obtained through the use of any information herein.