Have You Notified Your Payer Today?
In theory, the payer notification process seems so simple, but, it is not. In reality, “no notification”, is one of the top denial reasons. A member gets admitted as a patient into the hospital, the hospital notifies the payer that their member was admitted, and the notification is complete. Then for the remainder of the stay, the hospital must follow up with the payer for the pre-certification and days approved. This laborious process requires a team of employees to be on the phone and navigating payer websites and portals for hours each day. Some small payers still require a specific form to be faxed to them and some payers limit the number of pre-certification requests allowed in one phone call. Thus, requiring multiple call backs and being placed on hold for extended periods of time. Can this process be made easier? Of course, it can and here’s how:
Know Payer Rules
Every payer is different and knowing their specific rules or requirements on notifications is important in preventing denials. Some payers require the hospital to notify them literally within 24 hours of the admission and some require the next business day. Some payers will deny the whole stay if not notified in the required timeframe, some only issue a partial denial, and some issue a $500 penalty. By becoming familiar with the notification rules for each payer, hospitals can prioritize the work for the notification team and avoid unnecessary denials.
Streamline the Process
Cross training, automating, and working real time are other ways to optimize the notification process and make it easier for the hospital. Cross training the staff equips them with the knowledge to be able to work multiple payers. This eliminates a single point of failure and always ensures coverage for notifying payers and therefore, preventing denials. Automating the notification process by setting up the hospital’s system to send electronic messages (called a 278 transaction) streamlines the process and increases productivity by removing the human intervention. Not all payers allow for a 278 transaction, but it is well worth it to find out those that do and get it set up. Finally, working real time, meaning at the time of admission, ensures a timely notification to the payer and allows for some wiggle room if any issues with the payer or hospital arise that need to be addressed right away to prevent a denial.
The hospital has a whole team that is dedicated to the notification/pre-certification process because if not done correctly and timely has a direct impact on reimbursement. Having proof of the notification to the payer and proof of the number of days approved by the payer significantly reduces the amount of unnecessary work by the hospital when having to appeal a “no notification” denial. This proof can be captured by recording all phone calls to the payers as well as electronically capturing screen shots of the payer website or portal with the date and time of the notification and any days approved. Proof of this process can overturn a denial and protect revenue.
So, while it seems the notification process is challenging, it does not have to be. If a hospital takes the time to know the payers’ rules and requirements, streamlines their process, and obtains proof of notification to the payer, it can be as simple as it should be. Have you notified your payer today?
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