Work with clinical areas to obtain authorizations — Ask them to involve access from the beginning
"Clear and open" lines of communication between the clinical team and patient access is the single best way to prevent claims denials due to no authorization, according to Aaron Robison, CHAA, a patient financial advocate at University of Utah Health Care in Salt Lake City. However, this step remains a significant challenge for the department.
"When an account appears on our work queue for authorization, we need to be able to go to that ordering doctor and his team to find out everything we can regarding why the test was ordered," he explains. Patient access staff members ask for any evidence to show that the test is medically needed.
This step is more difficult when external providers request to have procedures for their patients at the facility.
"It can be quite a challenge to get medical records from their office to submit to the insurance companies," says Robison.
Get "on same page"
With recent changes in healthcare and a strong focus on reducing medical waste, providers are becoming better communicators as to why they wish to have their patients undergo a certain test or procedure, says Robison.
"When everyone is on the same page, getting an authorization isn’t that difficult," says Robison.
He adds that a clear precedent has to be set to encourage good communication between clinical and financial teams.
"It is only through good communication that the organization can avoid nasty appeal processes, as well as having to write off testing that would have otherwise been covered," he says.
A win-win situation
Providers and patients benefit from a better understanding of the role of patient access, Robison emphasizes.
"Instead turning to the department only after a denial has occurred, it is better to have them involved from the beginning with a patient’s plan of care," he says.
This involvement allows the patient access team to communicate with patients about their expected costs, as well as keep an eye on any treatments that might require an approval. For example, if a patient might require a second infusion of donor cells after undergoing a stem cell transplant, providers in the bone marrow transplant department inform patient access of this requirement. "It is in their best interest to give us a heads-up on a possible second stem cell infusion," says Robison. "That way we don’t find out at the last minute."
Patient access is then able to obtain an authorization if one is needed. "I have found that providers respond to the hard truth of potential monetary losses when poor communication is prevalent throughout a department," says Robison.
"Everyone wins" if patient access and the clinical care team work together during a patient’s treatment, he emphasizes.
"In this light, you are creating a continuum of care for the patient. The care team is not just for clinicians," says Robison.
