Friday, July 13, 2001

Red tape to delay med tests

Insurers' refusals proving costly, TriHealth says

By Tim Bonfield
The Cincinnati Enquirer

        Patients at TriHealth hospitals may find themselves waiting a few extra days for diagnostic tests and other procedures — and some might wind up stuck with the bill — because TriHealth is cracking down on paperwork problems.

        Last year TriHealth, which operates the Bethesda North and Good Samaritan hospitals and a variety of other medical services, faced more than $20 million in payment denials from health insurers who claimed that TriHealth provided the services without the proper referrals and preauthorizations, said Dr. Richard Smith, senior vice president of clinical development.

        Eventually, the hospital was able to collect about 75 percent of the initially denied claims, Dr. Smith said, but when all the faxing back and forth finishes, the hospital may end up eating about $5 million for unpaid services.

        TriHealth sent a letter in June to area doctors stating that it will slow its scheduling of some medical tests. It urges doctors to speed up their end of the paperwork flow.

        “Tests requiring authorization follow-up by TriHealth will be scheduled at least five business days after receipt of the needed clinical information, to give us adequate time to attempt to obtain the authorization,” the letter states.

        If the paperwork is not completed in advance, yet TriHealth services are provided, then patients will be asked to sign letters agreeing to pay any denied claims.

        “We're not trying to suggest to patients, "Hey, we don't want to do your test,'” Dr. Smith explained. “We're just trying to make sure we have the referrals and authorizations prior to services being provided.”

        On one hand, the amount of money tied up in these unpaid claims is a fraction of the hospital group's total revenue. On the other hand, the total amount of denials was up from previous years, he said.

        Be it $20 million or $5 million, the amount of money is big enough to make a difference. TriHealth reported about $34 million in losses in fiscal 2000, which ended June 30. It expected to lose some money in fiscal 2001, but final figures were not available, he said.

        In the past, hospitals have complained that some insurers make a habit of delaying claims payments. But TriHealth makes no such allegations in this situation.

        “We have seen nothing to suggest that (managed care organizations) are doing any of this deliberately,” Dr. Smith said.

        Some doctors say these payment denials are more often a result of health plans second-guessing doctors' patient care decisions.

        “For us, it's frustration and hassle. For patients, it's care,” said Dr. Pete Caples, a member of the Ohio Heart Health Center.

        Just this week, for example, Dr. Caples had a patient who had received approved treatment from a vascular surgeon while in the hospital but later was denied authorization to see that same surgeon for a follow-up office visit, because the surgeon wasn't part of the health plan's network, he said.

        “It's crazy all around,” Dr. Caples said.

        Many hospitals here and nationwide are dealing with the same kind of problems, said Gail Myers, spokeswoman for the Health Alliance of Greater Cincinnati.

        The Health Alliance's 2002 budget calls for $9 million from a variety of efforts to improve bill collection, including efforts to make sure authorizations for procedures are in order.

        “This is an issue for us,” said Ms. Myers. “A lot of folks are working harder to get that preauthorization so this kind of thing can be avoided.”


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