Pursuing Third Party Billing – A Change Project to Decrease Insurance Denials WESTBROOK HEALTH SERVICES PARKERSBURG, WEST VIRGINIA TEAM MEMBERS JOANN POWELL,

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Presentation transcript:

Pursuing Third Party Billing – A Change Project to Decrease Insurance Denials WESTBROOK HEALTH SERVICES PARKERSBURG, WEST VIRGINIA TEAM MEMBERS JOANN POWELL, EXECUTIVE DIRECTOR, KEVIN TRIPPETT, CFO BILL MARRS, CHANGE LEADER ANGIE HARSHBARGER, LINDA CANARY, TONNIE RUTHERFORD, BILLING STAFF

The Aim – Improve the Authorization and Payment for 3 rd Party Services Historically, commercial insurance has been a minor payer source at our agency, representing less than 5% of our billable total We wanted to prepare for Healthcare Reform and the increased volume of commercial insurance we would accommodate, while also increasing our efficiency in obtaining service authorizations and reducing denials Baseline denial rate for 3 rd Party Services was 7% (we had never previously even looked at this metric, so this was our starting point)

The Changes Centralization of Insurance Pre-Authorizations (previously we had a fragmented system across multiple sites and multiple administrative staff) Monthly reporting of denied services allowed us to identify patterns of denial, and make immediate corrections (e.g., pairing properly credentialed provider with insurance; modifying our pre- authorization form to better capture necessary information; improved tracking of re-authorization due dates to improve timeliness of service reauthorizations)

The Results Monitored the monthly denial rate (number of claims denied/number of claims submitted)

Discussion Monthly claims ranged between a low of 390 and a high of 719 Goal was to decrease the denial rate to 5%. We had a very positive result the first 4 months and then began a modest increase in denials in June and July. Why? Two clients in an IOP program both maxed their benefits, and accounted for 70% of our denials for June July timeframe. When removed from the sample our denial rate dropped below 3%...

Sustaining Results We’ve retained the change leader and billing department change team members as our sustentation group. Monthly tracking and identification of emergent issues hopefully will become the “norm” Credentialing and insurance paneling are also receiving monthly reviews for 3 rd party eligibility and currency New agency billing module will accommodate improved monitoring of authorizations and visit limits, also enhancing improved claims