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Create a denials infrastructure

Patient Access Weekly Advisor, November 28, 2007

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In order to map out a new denial management protocol at West Virginia University Hospital (WVUH), Christy Whetsell, BSB, RN, MBA, director of care management, began by designating centralized headquarters for all denials coming through the system.

Because case management already worked as a liaison between so many departments and followed patients across the continuum of care, a multidisciplinary team voted unanimously to make it the gatekeeper of denials.

"The next crucial step we took was to help define all the different types of denials and assign who would be responsible for each type," says Whetsell.

For example, case management would oversee inpatient denials while patient access would handle all preoperation denials. "Assigning responsibility was huge, because before everybody was essentially responsible, which meant nobody was responsible," says Whetsell.

Once WVUH's denial infrastructure was in place, the multidisciplinary team focused on the communications component-getting the word out to payers. Whetsell sent out letters to all the different insurance companies explaining that all denial notices should be sent to the case management department.

"We had to get everyone on the same page, both internally and externally," says Whetsell. "Insurance companies would send notices to physician's offices, to different departments, and they would get lost in the maze. We spent a lot of time reaching out to payers to get them to understand our new system."

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