Proving Payer Preauthorization
Qualify for a free subscription to HealthLeaders magazine.
Health First of Rockledge, FL, like many providers, found itself playing a familiar he-said, she-said, cat-and-mouse game with insurers, says Jim Slate, vice president of revenue operations for the health system.
“They would give us preauthorization to perform a procedure for a patient and they denied the claim later, saying we didn’t get the authorization,” he says. “We did, but it might have been a phone conversation and we couldn’t prove it. We had that happen many different times.”
Clearly, they needed a solution that would prove that prior authorization had been given, because while denials weren’t going to drive Health First out of business, they were putting a significant dent in revenue, as Health First’s denials were equivalent to about 0.3% of a gross of $1.5 billion annual revenue.
“That ran us in the range of $4 million to $5 million a year,” says Slate, “plus the cost to collect involved when you appeal, including time on the back end, and you have to produce medical records, which meant a lot of unnecessary work. Even if you do get it overturned, there’s additional cost involved.”
Health First needed an efficient way to track and archive those phone and fax communications so that insurance companies couldn’t hold their own disorganization against the hospital. It picked Trace, a searchable, Web-based program from The White Stone Group in Knoxville, TN, that logs and tracks phone calls and faxes much as how Microsoft’s Outlook catalogs e-mails.
Michelle Fox, director of revenue operations/patient access, says some insurers played this game cynically, meaning they knew the hospital didn’t have a record of the communication that authorized the service, so they knew they could get away with not paying.
“This really cut the feet right out from underneath the managed care folks who didn’t want to work with us,” she says. “Once you’ve established that integrity in communications, the customer knows that, so there’s no more game playing. You don’t have to do the battles, and they can’t deceive you through miscommunication.”
But collections weren’t all that the new tracking system improved.
- Hospital Groups Strike Back at Hospital Rating Systems
- AHIP: Enormity of HIX Challenges Sinks In
- The Secret to Physician Engagement? It's Not Better Pay
- 5 Hot Healthcare Ideas from SXSW
- How Succession Planning Boosts Employee Retention Rates
- Another SGR Patch Likely, Lawmaker Says
- 4 Reasons PCMH Principles Aren't Going Away
- Two-Midnight Rule Must be Fixed or Replaced, Say Providers
- Don't Underestimate Emotional Intelligence
- Evidence-Based Practice and Nursing Research: Avoiding Confusion