SSM Health Care Partners With RSource to Maximize
Patient Non-Compliance Denial Recoveries
Academy research indicates that 11% of all claims are denied, representing a significant
portion of a healthcare organization’s revenues that require re-work before receiving
reimbursement. Often, the re-work for denied claims involves obtaining additional information from the patient before the insurer will pay. If the healthcare organization does
not have adequate resources, these accounts can be very time consuming and produce
few positive results.
Highlights
Profile
•SSM Health Care
•17 Hospitals in 4 States
•$2.9 billion NPR
•7,300 physicians and more than 25,600
employees
Challenge
•After centralizing their business office,
SSM Healthcare found an increasing
number of “information needed from
member” denials
•These denials require additional information from the patient but often
patients are not motivated to help the
healthcare organization receive reimbursement from third party payers
•This took control away from the hospital and introduced a barrier to timely
account resolution
Solution
•SSM Health Care decided to partner
with RSource to resolve these denials
that were using up the health system’s
resources
•After attempts to contact the patient
via phone and mail are unsuccessful,
SSM refers the account to RSource
• From there, RSource utilizes attorneys to
review the account and diligently followup by contacting the payer, the patient,
or both until the account is resolved
Results
•RSource collected over $1.2 million
during the pilot program at SSM
•They also provided $6.5 million in total
account resolution
•The average account resolution time
for RSource was 75 days
•SSM expanded the program to all
of their hospitals after the initial pilot
program
There is a variety of information that might be needed from patients prior to insurers paying claims, including:
• Medicare CWF Updates/Corrections
• Coordination of Benefits
• Pre-Existing Documentation
• Accident Details
• Eligibility Information Updates
• Medical Records from Other Providers
Patients often express little motivation to help provide information needed for the
hospital to receive payment from the third party payer, creating an A/R backlog.
Many hospitals and health systems convert these accounts to self-pay, which then
places the patient in an adversarial role with the hospital and creates an even higher
cost-to-collect. In addition, The Patient Protection and Affordable Care Act now ties
future reimbursement to patient satisfaction, and claims denied for patient noncompliance can cause serious patient satisfaction problems if not handled in the
most effective manner.
SSM Health Care was experienc“If we weren’t sending these patients to
ing difficulties related to resolvRSource, they would be going to bad debt. It
ing claims that required additional
is better for everybody involved.”
information from patients. SSM
– Kevin Kreitner
Corporate Manager, Quality Audits & Vendors
Health Care is a Catholic, not-forSSM Health Care
profit health system with an international reputation as a pioneer in the
use of quality measures to improve care. SSM operates 17 hospitals in four states—
Wisconsin, Oklahoma, Illinois and Missouri. The health system has $2.9 billion in net
patient revenues with 4,093 total licensed beds and 7,300 physicians. The Academy
recently spoke with SSM to learn about their processes and their partnership with
RSource, a solution provider that specializes in problem claims and denial recovery.
Challenge
SSM had gone to great lengths to decrease denials internally—including the creation of a central business office for their six St. Louis hospitals. This helped improve
the healthcare system’s pre-registration and financial clearance processes. During
this process, SSM identified a significant increase in denials for “information needed
from member.” The denials ranged from COB updates to request for accident information. These types of denials removed control from SSM and presented an obstacle for
timely account resolution.
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The standard process at SSM for these types of denials had historically been to attempt patient contacts
with calls and letters and then if the patient did not
respond, move the balances to patient responsibility—and eventually bad debt. This practice of treating the account balance as a self-pay balance when
the patient did in fact have coverage was not producing the desired results nor following the mission
of SSM.
Solution
Resolved Inventory at SSM Health Care
$6,753,491
$3,349,863
$3,227,726
$1,204,853
$175,902
Early in 2011, SSM was introduced to RSource, an
Net
Paid Account
Cash
Verified SelfEfforts
attorney-led patient advocacy revenue cycle partner.
Assigned
Resolution
Collections
Pay Account
Exhausted
SSM was impressed with the approach RSource had
Resolution
created in resolving patient non-compliance denials.
During the pilot program, RSource recovered over $1.2 million for SSM Health Care.
RSource utilizes a patient advocacy approach including home visits and attorney intervention directed
toward the payer, not the patient, to accelerate the resolution of these accounts. Their approach focuses on patient education and
support to gain cooperation from the patient, and in many instances, RSource resolves the underlying issue by working directly with
the payer and avoiding patient involvement. In May of 2011, SSM partnered with RSource in a pilot program to resolve all “information
needed from member” denials for 6 of its 17 hospitals.
For SSM, the automated process begins when an “information needed from member” denial is posted to an account. Once the denial has
been received, SSM has an internal process in place to generate a series of letters and phone calls to reach out to the patient. If there has
been no response from the patient at approximately 120 days from the patient discharge date, an internal system code of “uncooperative”
is assigned to the account. The “uncooperative” code produces the referral to RSource, and they perform an initial attorney review. After
the review, RSource begins the process of contacting either the patient or the payer and takes the steps necessary to resolve the account
based upon the information requested and the primary payer.
These steps include hosting three-way calls with the patient and payer and after hours or weekend calls to contact patients when they
are more likely to be available. In addition, attorney intervention with the payers often eliminates the need for documentation that was
previously required, and if necessary, RSource will also send patient advocates for home visits. The following are the steps RSource took
to resolve an actual account for SSM where a patient’s account was pended by Anthem for a COB update—the account was referred to
RSource 122 days after the date of service:
• RSource contacted the patient and confirmed that neither she nor her husband had any additional insurance on the date of service.
• RSource then contacted the carrier with the patient via a three-way call and attempted to provide this information. Anthem, however, stated that this information had to be provided in writing and sent out another form to the patient that day.
• RSource left additional messages following up with patient and continued to follow-up with Anthem. The member did not initially
return the form.
• RSource continued to diligently follow-up with the member until the requested form was eventually submitted to Anthem. Anthem
completed processing and payment was issued.
Through their diligent follow-up process RSource was able to collect $37,544.12 for SSM on this account when the original charges
were $50,716.95.
Results
Since implementation of the pilot project, RSource has recovered approximately $1.2 million in actual cash collections for SSM. In addition, RSource has provided over $6.5 million in total account resolution, with an average resolution time of 75 days. Importantly for SSM,
this program is consistent with their efforts to maximize patient satisfaction, especially in light of the new Value-Based Purchasing component of the Patient Protection and Affordable Care Act. With the success of the pilot program, SSM made the decision to expand the
RSource patient non-compliance program to the rest of their hospitals and accelerate the timeframe for referral of accounts to closer to
60 days after the patient discharge date.
About RSource:
• RSource is an attorney-led healthcare receivables management company that specializes in the timely resolution of third-partypayer claims.
• They customize receivables management solutions that maximize and accelerate cash collections for healthcare organizations.
• RSource has experience dealing with all payers, including health insurers and managed care companies, workers’ compensation
carriers, motor vehicle and liability carriers, Medicare and Medicaid, and the Veterans Administration.
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