Illinois’ largest Catholic health system, Presence Health, is using Trace to document and manage revenue cycle communication for improved reimbursement, compliance and quality assurance. Revenue cycle departments capture communication with physician offices and insurance companies, backing up activities and keeping staff connected across the continuum.
When talking with insurance companies, Insurance Verifiers at Presence Health record phone calls stating the patient’s benefits and account number. If the hospital later receives a denial, the team can retrieve the recording through Trace to show that the payer provided authorization for the appropriate account number.
“Trace has given us a great history of success in overturning denials,” said Eleanor Michalek, System Director of Patient Access at Presence.
In one case, the hospital had a patient that was categorized inpatient but stayed at the hospital for less than 23 hours. According to the managed care contract, the patient’s insurance did not require authorization for an inpatient stay of less than 23 hours. When the hospital later received a denial for $42,000, verifiers used the Trace recording to overturn the denial, as well as a $1,000 charge for late notification.
Presence Health also uses Trace in Care Management to record clinical precertifications from insurance companies.
“Without the recording capability we would be at a much greater risk for denials and unsuccessful appeals.”
The Insurance Verification team at Presence Health sends faxes to physician offices requesting that the physician initiate the authorization process. If the office says they did not receive the fax, the hospital has proof that they did indeed send it. They can also call the physician office on a recorded line to ask them to initiate the authorization and then resend the fax through Trace.
“Trace is a workflow tool that helps our team be more productive, while also keeping an audit trail of all our activity,” said Paula Schmitt, Insurance Verification Manager.
Since Trace documents the hospital’s communication with physician offices, the pre-Registration team can easily look up the account when a patient’s procedure is approaching. If the hospital has already reached out to the physician regarding the authorization, staff can confirm that with the patient.
“It reassures the patient to know we are technologically advanced and are tracking everything,” said Michalek. “Trace makes us appear as professional as we are and shows the patient that we’re working for them.”
“Trace has provided our staff with a high level of confidence,” said Schmitt. “We have all the faxes right there. It’s easy to use, and it’s reassuring to have all the data in front of us so we can back everything up with facts.”
Trace also serves as a quality assurance tool to provide training and support for staff members at Presence. If a physician says that a team member was rude, for example, supervisors are able to retrieve recordings to find out what actually happened. “I can even review the recording with the physician office manager over the phone,” said Michalek. “It shows that I’m in touch with my staff, and I know what they’re doing.”
Presence randomly selects five accounts per verifier each month to perform quality assurance of phone calls. Supervisors compare recordings with what has been documented for the account and confirm that benefits have been entered correctly. If the verifier does not meet the necessary Quality Review score, the frequency changes to weekly reviews.
This also provides a way to back up and support team members. “Staff can listen to themselves and see where they may not be coming across in the way they were trained – such as using the wrong terms or not sounding as professional as they could.”
Presence Health is currently expanding its use of Trace to have consistency across all hospitals. The health system also plans to implement voice recording in Central Scheduling and increase its use of quality assurance for calls with patients and physicians.
To download a PDF of this case study, click here.