ATLANTA – The variability of payer decisions on coverage is no joke for providers.
They often base treatment decisions on precertification efforts, then find that payers deny submitted claims. When hospitals go to dispute the denial, they typically have scant evidence – often, a staff member’s vague recollections.
“Before we could record anything, it would just be what my staff member happened to remember about a phone call,” said Kim Miller, former director of patient access for Children’s Healthcare of Atlanta. Sometimes, her staff got precertification information from a payer’s Web site, and it was impossible to recreate that information in the event of a denial.
But the Atlanta-based healthcare system has leveled the playing field with an application that is able to record phone, fax and other electronic communications, such as Web site images.
Children’s Healthcare of Atlanta, the largest pediatric healthcare system in the country, last year mandated use of Trace, developed by Knoxville, Tenn.-based The White Stone Group, in all its care settings.
The stakes can be high. Trace recently helped provide evidence to overturn a denied claim of more than $450,000.
Without strong evidence, providers typically have weak evidentiary support in fighting claims denials, said Guille Cruze, White Stone Group’s CEO. “It gets to be one person’s word against another’s. Healthcare is another case where, tragically, honesty bears the burden of proof.”
With Trace, Children’s Healthcare of Atlanta can record any communication when staff members are interacting with payers about patients’ cases. The records are captured, indexed and archived for retrieval through a central Web-based tracking system.
“This makes it very efficient for us, for the person who is following up on denied claims,” said Florence Davis, patient access manager for Children’s Healthcare. “They can go to one place and pull up every conversation that we had with a payer.”
Davis estimated that the healthcare system has captured nearly $2 million in overturned claims. In addition, she’s been able to restructure the duties of staff who had to contest denials with payers; now, with archived evidence, their job is a little easier.
Because Children’s Healthcare gathers this evidence from the start – and because payers know their reputation – Miller believes the system is able to thwart claims challenges pre-emptively.
“The way we’re using the tool, we’re getting claims denials overturned before the claim goes out the door,” Miller said. “I estimate we’re saving millions on the front end because we’re saving money on what we otherwise would be paying trying to overturn denials.”
Miller says the application also provides benefits for customer relations. For example, when physician offices fail to provide needed documentation for authorizing procedures, the system can record those conversations. And the system can provide documentation when patients’ insurance policies contain provisions that affect their copayments.
“Customers aren’t savvy about the insurance plans they’ve chosen,” she said. “When we call them about a missing authorization or higher deductible amounts, a lot of times they think we’re the bad guys,” she said. “Now, we can put this back on the insurance companies – we have the proof of what it is that we’re relaying to them.”