Simplifying Managed Care Communications

April 1, 2007

A case management department implements time saving technology that overturns nearly $700,000 in denials.

For years, providers have sought a reliable, automated solution to the time-consuming and error-prone process of claims reimbursement. On the front end of patient care, countless hours are spent working to notify and secure authorizations from differing payer organizations, each with its own set of unique processes and criteria. On the back end, collections will spend equally large amounts of time struggling to supply evidence necessary to overturn denied claims. All too often, the difficulty prevents any attempt at overturning the denials.

A case management department implements time saving technology that overturns nearly $700,000 in denials.

For years, providers have sought a reliable, automated solution to the time-consuming and error-prone process of claims reimbursement. On the front end of patient care, countless hours are spent working to notify and secure authorizations from differing payer organizations, each with its own set of unique processes and criteria. On the back end, collections will spend equally large amounts of time struggling to supply evidence necessary to overturn denied claims. All too often, the difficulty prevents any attempt at overturning the denials.

New Managed Medicaid laws have increased the number of procedures requiring precertification (precert). This, coupled with increased admissions, has nearly doubled the workload for many case management departments. Providers are now challenged to complete a significantly larger volume of transactions while limiting the number of new hires.

These challenges are no different for us at Deaconess Hospital. As the flagship hospital of Deaconess Health System, a three-campus, 630-bed system, Deaconess Hospital is a 381-bed facility in Evansville, Ind. situated on a 20-block campus. As manager of Case Management Services, I was acutely aware of the need to better manage the magnitude of communication with payers and re-engineer our case management processes to maximize staff time, improve workflow and provide documentation to resolve payment disputes.

The Challenge
In the case management department at Deaconess, one of our biggest problems was the staff time wasted on hold during phone calls with insurance companies. There were many times that my staff routinely waited on hold for 20 to 30 minutes for a precert, only to be disconnected due to technical issues, business closings or other issues.

Payers also began limiting calls to three or four precerts, which required case managers to call back and wait in the hold queue numerous times for additional patients. With five employees multitasking between case management, utilization review and discharge planning, the hold time dilemma became a growing hindrance to our department’s productivity and job satisfaction. In addition to hold time, we were frustrated by the “chit-chat” and redundancy that often accompanied live-phone conversations.

Our department also struggled to document various communications with payers for later evidence in payment disputes. In case management, we were often unaware of the denials received on the back end due to lack of notification or authorization. Because it was nearly impossible to provide tangible proof of communication, disputes often came down to our word against the insurance company’s.

As a result of these challenges, we began to evaluate solutions to decrease the time spent on hold and reduce denials with evidence of communication. Our goals were to improve productivity without increasing FTEs, as well as arming ourselves with proof to back up our work.

The Solution
In our process of finding a technical solution to this challenge we were introduced at a national conference to VoiCert, the voice-based call management component of the TRACE suite of products from The White Stone Group (TWSG). The suite of products in their entirety can capture, archive and index digital files of phone, fax and electronic communications for retrieval through a Digital Communication Record (DCR) Tracker, which features a user-friendly Web interface. We requested a demo and in January 2004 we implemented VoiCert Automated Call (AC), which automates and permanently records notifications, authorizations and other transactions conducted by phone.

A critical factor in our decision to implement VoiCert was its ability to eliminate call hold times while digitally recording, indexing and archiving calls for evidence in the denial and appeals process. The system bridged the gap between our front-end and back-end processes and provided documentation to overturn denials. It was also the only solution we identified that allowed us to automate, capture and index calls for later retrieval. Cheryl Wathen, our director of finance was instrumental in our choice, and based on our cost justification summary, we projected a return on investment (ROI) in 17 months.

Implementation and Training
Following our purchase of the product suite, we selected a product steering team that included our chief financial officer, director and manager of information services, director of finance, director of patient financial services and an application analyst. The system was initially introduced at the Deaconess Main Campus and The Women’s Hospital and expanded to the entire hospital system within four months.

Implementation required little change to the existing infrastructure at Deaconess. System analyst Mike Nunnelly was pleased to find that the server would simply be a rack mount install in our data center with T1 connectivity to our phone switch. TWSG provided remote installation and support of all software applications through a VPN connection.

As product administrator, I worked one-on-one with an account manager at TWSG to set up user codes and voice prompts for the system. Usability was critical to ensuring the success of a new technology among a staff accustomed to the current process. The company provided support to address training challenges for my staff and participating payers in using the new system. Intensive on-site training focused on key users and department managers, supplemented with implementation guides and individual training tools for each staff member. Within an hour of training, the staff began using the system.

The manufacturer provides ongoing support to assist in the assessment of use patterns, trend analysis and appropriate documentation for the appeals process. A company representative account manager makes regular on-site visits to tune usage, provide further training and even celebrate denials overturned with the system. Product upgrades, server quality checks and extended customer and technical support all are provided under our mainten­ance agreement.

How Things Work
With VoiCert AC, the case manager calls the server and is voice-prompted for specific demographic and clinical information required by a particular payer. When the case manager hangs up, the server calls the payer and navigates the phone tree, then waits on hold to deliver the information. After retrieving the payer’s response, the system automatically delivers it to the originating case manager’s phone or voice mail. The entire call is then archived and available for retrieval and playback through DCR Tracker.

By shortening a typical 30-minute phone call to two or three minutes, our department now manages a greater workload without an increase in FTEs. Due to the reduction, we have saved more than 4,800 hours in staff phone time. Over a three-year period, this figure represents a recovery of nearly $96,000 in payroll dedicated to payer communications. Because the system is operable 24/7, automated calls can be input during off hours and delivered to the payer during its regular hours of operation. This helps us to streamline workflow and avoid phone-time bottlenecks after long weekends or holidays.

In the realm of case management, proof of authorization for care is just as vital as security and accuracy of personal information. Since claim denials require us to revisit all aspects of the case, it was imperative that our solution provided a way to shorten the denial resolution process with payers. Captured calls via the system are indexed by patient ID or account number, and can easily be retrieved via DCR Tracker. These archived phone calls provide proof of a patient’s authorization for care.

With an accurate indisputable record of communications, we now hold a position of strength in the all-too-common “he said, she said” dilemma. For example, if Patient Financial Services receives notice of a denied claim for lack of precert, they can easily search for the record. TRACE allows a recording of the payer verifying the authorization to be played over the phone or delivered to the payer as a written transcript for verification.

Expansion
Shortly after the integration of the VoiCert portion of the product suite, the provider upgraded our system with VoiCert Monitored Call, a feature that allows us to index and record live outbound calls to insurance companies. This was covered under our maintenance agreement and has significantly increased our ability to overturn denied claims with payers not participating with the Automated Call feature.

To encourage initial usage, we distributed weekly reports showing the minutes saved with VoiCert each week. Administration and the steering committee also are notified each time the system is used to overturn a denial. At the end of 2005, our case management department had used system data to overturn $368,000 in denied claims, resulting in a 206 percent ROI within the first two years of implementation. By the end of 2006, this figure increased to $689,635 bringing our ROI to 387 percent.

We are currently working toward implementation of the product suite’s FaxCert and PixCert software for the management of fax, paper, Web and electronic communication. The FaxCert application captures inbound and outbound faxes through the server as a by-product of our existing fax infrastructure. FaxCert also archives transmission data such as proof of receipt, sender/recipient and date/time information. With the full suite online, DCR Tracker allows us to view, route, print and resend faxes from our PCs instead of re-faxing and routing paper copies.

The PixCert application offers the same management capability for electronic and Web transactions. PixCert captures any electronic document, Web page or e-mail and indexes it to a specific patient for retrieval through DCR Tracker. PixCert allows us to document authorizations, eligibility, verification of benefits and other transactions completed on payer Web sites or via e-mail. This will eliminate the need to print and file paper copies, saving us time and improving the accuracy of our documentation.

By using the solution to automate and capture phone communication with payers, we have received a return of approximately $800,000 in timesavings and overturned denials. With the addition of the suite’s FaxCert and PixCert software, we will have even greater ability to capture and archive communication events to back up our billing, streamline workflow and maximize staff efficiency.

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Sally Finley, RN, is manager of case management services at Deaconess Hospital in Evansville, Ind. Contact her at  sally_finley @deaconess.com.

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