orm_february-2024 - 29

OR Business
nication from the facility. However, there
is often a good reason for that. " They
think we've forgotten about them, but
what's happening is that we're waiting
for insurance verification. A care coordinator
can help avoid miscommunication.
Ours is a godsend; the work she
does on the back end is amazing, " says
Smith.
EHR systems such as EPIC and
Cerner are some of the tools used to
share and communicate information
today. However, they are imperfect and
weren't designed to track and manage
workflows or connect all stakeholders
coordinating care. " It's clunky because
there isn't one place to see everything,
and while everyone has access, with
EPIC, your lens is a little different depending
on your job, " says Smith.
When an employee from imaging
logs in, they will see the imaging
template. However, someone from another
department cannot access those
images with their login. They need to
choose a different job/department.
Smith's care coordinator must log in as
a different job to reschedule rehab for a
patient.
" Being a rural organization, we lease
EPIC through a larger organization. We
don't control the building and development
of what we need [in the software].
Certain programs aren't available for
us. You can ask for them, but it'll take
three months to a year. So if you have
a problem right now, you have to find a
workaround, " says Smith.
Another complication
with faxing is security
and protecting patient
information. " You get
one number wrong, and
you're sending someone's
chart to a mechanic
in Detroit. That
possibility is unnerving,
yet the medical industry
Joshua Ast,
MSN, RN,
CNOR
still heavily relies on faxes to transmit
medical information, " says Joshua Ast,
MSN, RN, CNOR, director of surgical
www.ormanager.com
services at White Rock Medical Center.
Kim Viadero, BSN,
RN, CNOR, surgical
services administrator,
says that problems
can range from blurred
EKGs and unreadable
numbers to missing
pages and paper jams.
" The cardiac clearance
may be on page five of
Kim Viadero,
BSN, RN,
CNOR
a 20-page fax, and that page is missing, "
she says.
An OR scheduler has to be great
at multitasking, communication, and
project management to ensure surgical
case requests are initiated and properly
coordinated leading up to the procedure.
Manual processes along the
way make care coordination a cumbersome,
mistake-prone process for any
OR scheduler.
Third handoff: Prior authorization
Insurance companies have a litany of
requirements before signing off on surgery.
If one item of information is missing,
the risk of a delay or cancellation
is almost guaranteed. Insurance companies
do not make it easy for staff to
verify cases last minute.
Insurance verification depends on
collecting all the necessary case and
patient information early to complete
the verification process correctly. The
case coordination process is often delayed
or at a standstill until verification
is finished at the surgical facility. The
insurance verification team can spend
many unproductive hours collecting
missing information to complete a case,
causing delays with all the stakeholders
in the process.
" We probably spend a minimum of
5 hours a week making phone calls to
track down information, " says Ast. " This
can lead to overtime because we're
trying to avoid canceling the case. The
doctor's office could be closed by the
time they can get on the phone to make
calls. "
Because insurance
verification is multilayered,
it is difficult
to track whether or
not cases have been
verified. Most facilities
need more visibility into
the process and a foolproof
method to track
Brittney
Williams, RN
incomplete verifications. " There are frequent
instances where we're cutting
it down to the wire, making constant
phone calls back and forth, " Williams
says. " It's the day before surgery, and
we're still asking if we're approved. And
if we're not, we have to reschedule.
Patients have already rearranged their
schedules for this, so it's a huge inconvenience
for them. "
Regulatory guidelines dictate the site
of service, billing, and reimbursement of
any procedure based on the patient's
profile and case type. These guidelines
help guarantee that each patient gets
safe care and the most optimal outcome.
If any of these guidelines were
compromised, it could equate to reimbursement
denials, resulting in lost
revenue for the facility.
" Last year, we had three hysterectomy
denials because we didn't have
the sterility consent 30 days before
surgery, " says Smith. " The typical reimbursement
for hysterectomies is between
$30,000 and $48,000. Multiply
that by three. And that doesn't account
for supplies, time, and staffing you just
utilized for free. "
Something as simple as not having
the correct insurance on file is costly.
Smith says her facility has just under
$1 million in insurance denials. Online
portals like MyChart make updating
their records easier, but not every patient
has an account.
Another new trend: because outpatient
surgeries are less expensive, insurance
companies are reluctant to pay
for inpatient surgeries if not medically
necessary. Age isn't necessarily the
deciding factor.
OR Manager | February 2024 29
http://www.ormanager.com

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Table of Contents for the Digital Edition of orm_february-2024

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