Establishing Undeniable Proof to Fight Denials and Win at Community Health Network

KEY INITIATIVES

  1. Document authorization, insurance verification and notification activities – voice, fax and electronic – for proof to prevent and overturn denials.

  2. Convert to paperless workflow with electronic faxing and image export to the EHR.

  3. Centralize insurance exchanges for enterprise access to reduce rework and shorten appeals process.


PROJECT SUMMARY

Community Health Network uses Trace by Vyne Medical to record phone conversations, send/receive faxes and capture activity from web sites and other hospital systems. All activity is tied to the patient account and centrally stored for enterprise access and exchange.

  • Denial team receives denial or request for more information

  • Team checks EHR for reference number to voice recording, fax or image; retrieves record for proof to fight denial

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If proof is found in voice recording:

team sends transcript of recorded call showing proof of authorization or agreed-upon level of care

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If proof is found in fax:

team sends documentation letter showing content of fax and date/time stamp for proof of timely notification or of clinicals being delivered

  • Denials routinely overturned using proof of these interactions

  • No more rework and back-and-forth between departments


PROJECT IMPACT

 
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Workflow

Challenge

Disconnect between care management and patient access

Action

Care Management absorbed employees from patient access center and surgery authorization verification team

Result

Streamlined workflow and strengthened denial management with additional patient insurance representatives

 
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Communication

Challenge

Disconnect between care management and backend departments

Action

Trace® applications implemented for voice recording, electronic faxing and image capture

Result

Authorization, notification, clinicals and level of care activities are documented, indexed and centrally stored

 
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Time

Challenge

Time spent on manual tasks such as printing and scanning

Action

Care management implemented Trace electronic faxing and integration tools for automatic export of images to the patient record

Result

Streamlined care management workflow and eliminated the need to print, scan and manually fax information


Project Outcomes

Reduced Denials

  • Denials team references voice recordings, electronic faxes and images to win appeals

  • Utilization Review references voice recordings to verify patient coverage and stop denials before they start

Impact

In 2018 alone, Community overturned over $30 million in initial denials.

 
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Time and Cost Savings

  • Utilization Review has direct access to information needed to support claims

  • Electronic faxing and image export reduce paper and machine costs. Non-clinical staff process faxes and alert appropriate case manager, to reduce administrative burden for RNs

  • Back-end works accounts faster with fewer manual touches and less rework between departments. Denial management team completes reviews in a more timely manner, leading to earlier discharges and reduced length of stay

Impact

Community has responded to increasing demands from payers without increasing FTEs in UR or Denial Management. Initial plans to hire 5 additional RNs became unnecessary because of efficiencies gained with centralized access to care management data. This saved the network the equivalent of 5 FTEs with benefits.

 
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