BRENT GRIMES IS the Corporate Director of Patient Financial Services at INTEGRIS Health, a 13-hospital health system based in Oklahoma City, Okla., with 1,900 licensed beds and employing more than 2,500 physicians.
Grimes spoke with editor Richard Pizzi about some of the challenges his office is encountering, and overcoming, in 2010.
How is patient financial services organized at the health system level and at each of the hospitals?
Just recently we have had a mixed bag of a central business office with four of our facilities having an independent office. Over the past fiscal year we have moved into a true central business office in our headquarters in Oklahoma City. I do have a director on-site at each facility. Those directors are over the admitting departments, coordinate with the chargemaster and issue resolution on-site. Central business office handles the core customer services issues, patient collections, billing, follow-up, RAC audits, etc.
Has the recession increased the number of patients presenting at your hospitals with no insurance?
Definitely. There has been a very large increase in the amount of patients that are no longer covered by insurance due to layoffs. That has led to an increase in bad debt and charity care.
How big of a problem are payment denials for a health system the size of INTEGRIS?
It’s a huge issue, and there are multiple reasons for denials. It’s an ever-increasing problem. There’s really not one specific type that gives us overwhelming problems. At times it’s like “flavor of the month.” A lot of the health insurance plans now have limited benefits, and that’s become a bigger issue. It’s very difficult to find that information at the time of service. We assume a lot of liability with those plans.
Medical necessity denials are another type of denial that we consistently have to combat. You have to work with the clinical groups to get the proper documentation, work with the compliance team, coordinating education with the clinical groups.
Another issue is eligibility. Having patients present health plan ID cards at the time of service, when in reality they have lost those benefits. That has happened more frequently with the economic downturn. That can create a tremendous delay in processing for us if we don’t catch that at the very beginning.
What is the cost associated with denials?
Number one, of course, is the monetary value itself. When we have a claim denied, it’s a delay in our payment. That impacts the funds that our health system has available to acquire new equipment and offer new services to our community. An added expense is staff. You must have additional staff working on a denial unit. We have an entire team dedicated to denial management that is separate from the central business office. You also have to invest in software to produce the data to research what denials are preventable.
In regard to eligibility denials, are many patients unfamiliar with the kind of health benefits they have?
We have a lot of patients who will try to schedule services and are shocked to discover that they have a $5,000 deductible. We work to inform patients what their financial obligation will be as soon in the process as we can. In the past, when we weren’t as transparent, we received many complaints from patients. We have really worked hard at informing patients who have high deductible plans. We want to make sure they are aware what they will be billed.
How did you handle eligibility denials before you automated your system two years ago?
We billed the insurance, wait our traditional 20, 30 or 40 days to get return correspondence that the patient was no longer covered by the health plan, and was no longer eligible. Then we would turn it over to patient responsibility. That has financial ramifications, because you’re counting that patient as “after insurance” because they were never categorized as a true “self-pay.” That really skews your numbers, because that’s really not a true “after insurance” patient. It’s really important to capture that information on the front end.
Is there one entry point in the hospital that gives you the biggest problems with eligibility denials?
The emergency room. You have the least amount of time with a patient to discuss the financial obligations because in many cases the patient needs immediate medical care.
What improvements in managing denials would you like to see in the coming years?
The ultimate goal would be to tell a patient what their true financial responsibility was going to be at the time of service. That’s not the case right now.