Part 3: Silent Denials…What you don’t know hurts the patient experience and your bottom line

A final refresh of context, our story began with a transfer from a neighboring hospital. On the surface, the transfer seemed to be appropriate to accept…until it wasn’t. This seemingly simple transfer turned into a series of denied claims in excess of $500,000.

So, while it may seem obvious, having a transfer policy doesn’t equal protection from the scenario you just read. When was the last time you reviewed your transfer policy? If you don’t know, don’t wait until the next transfer happens. Prevent this silent denial before it slips in through the back door of your hospital.

Let’s pull out (and dust it off if it’s been more than a year) your transfer policy. Here are the final three questions (and answers) to use in testing it:

1) What is the patient’s role or the patient’s family role in the transfer?

There are many state laws about notification regarding discharge or pending transfer of the patient in the hospital. It is important to remember that HIPAA laws apply to all disclosure of information but generally speaking involving the patient’s family in a transfer decision is just good business. It is not unusual for a patient’s family to make a transfer request for clinical, geographical or medical reasons. In these cases, the requested transfers will not involve EMTALA. Therefore, it is essential to involve the financial clearance team and gather all the payer information prior to approval.

2) Do transfers between facilities in the same system involve less risk?

Not necessarily. Very few health systems have established national payer contracts, which cover all of their facilities. The result is that the patient may be in the network at one location and out of network at another. This is particularly true when the locations are across state lines. In these cases, the financial clearance team must remain vigilant because the patient, the patient’s family, and quite often the staff at the transferring facility, will assume an in-network patient will remain in the network.

3) What are the key components of a good transfer policy?

• Define the hospital’s typical capabilities and service capabilities and itemize those services the hospital is unable to provide.
• Establish a mechanism, so the transfer team knows on a real-time basis what ads, resources, and capacity is and is not available.
• Differentiate request for transfer acceptance directed towards specific facilities that are not based on capacity.
• Differentiate request for transfer acceptance from the ED versus Inpatient
• Differentiate between EMTALA transfers and non-EMTALA transfers. The pathway to follow will be different for the different types of transfer request both legally to comply with EMTALA and practically to determine the best place to accept the patient.
• Create specific documentation for recording the acceptance and rejection decisions, including what facility he requested to transfer to, the reason, the reason the transfer was rejected or accepted. If possible, conversations regarding the transfer of the patient’s condition should be recorded.
• For non-EMTALA transfers, the financial clearance team should be involved to gather all relevant payer information prior to acceptance of the transfer.
• For EEMTALA Transfers, the receiving facility should request all Payer information from the transferring facility that has already been collected from the patient, but this information should not be used in making the decision on whether to accept the patient or not.

Creating and implementing a well-designed transfer policy is the key to success in reducing the silent denials associated with accepting patients from other facilities.  Moving from a just always say “yes” policy to a modified “yes-no” policy may save providers upwards of hundreds of millions of dollars each year in unpaid/denied claims.  A well-designed, and properly executed, policy improves patient relations as well.  Involving the patient and advising them of their financial responsibility, including when they will be out-of-network and possibly responsible for all bill charges, goes a long way to building a solid patient-provider relationship.

Further reading: Think Digital-First: Enhance Denials & Appeals Management with Intelligent Automation

Disclaimer: This document is a summary perspective of the guest author. It does not represent a formal legal interpretation by the author or Firstsource.