Rule of the Month: Teamwork
The March Rule of the month illustrates how athenahealth teamed up with a national payer, Harvard Pilgrim Health Care, to reduce the number of denials due to missing referral or Primary Care Physician (PCP).
Denied claims slow down payment processing and waste the most valuable resource in your office – TIME!
The Problem:
A common reason for a claim denial is a missing referral. Once a claim has been denied for not having a referral the phone calls begin. The practice calls the patient, who then calls their PCP. The PCP calls the insurance company, and after all of those phone calls, the patient may need to call the office back to get everything straightened out. It’s a lot of phone tag for both the practice and the patient. athenahealth noticed this trend with many payers, but specifically with Harvard Pilgrim Health Care, and worked to reduce the need for athenahealth clients (and their Harvard Pilgrim patients) to make all of those phone calls.
The Solution:
athenahealth realized the need to solve this issue. The Denials Analysts and Development team worked together to develop possible solutions. Their goal was to be able to use PCP information gathered through eligibility transactions. Then athenahealth’s Payer Outreach team met with Harvard Pilgrim Health Care and they jointly reached a solution. athenahealth added new rules to the Rules Engine and today this new process has been very successful in saving our clients time!
How it works:
When athenaNet® checks Harvard Pilgrim patient eligibility and there is no PCP on file, the claim goes into HOLD status before it is submitted – allowing for the patient to select and register a PCP prior to claim submission.
In addition, when a patient is seeing a provider who is not the PCP listed on the eligibility file, a referral is required by Harvard Pilgrim Health Care. If there is no referral, the claim goes into HOLD status, again, before it is submitted - allowing the patient to obtain a referral prior to submission. athenaNet® even prevents claims from being submitted if the referral is not entered in the appropriate format!
athenahealth clients are pleased with the decrease in denials. Harvard Pilgrim Health Care is pleased with their improving standings in our PayerView annual rankings and athenahealth is thrilled with the opportunity to help our clients be more efficient. Everybody wins!
Continuous communication and teamwork between Harvard Pilgrim Health Care and athenahealth led to the creation of a streamlined workflow that benefits all of athenahealth’s Harvard Pilgrim clients. We look forward to more opportunities like this one that help our clients achieve better results. Stay tuned for next month’s athenaPulse Rule of the Month.