EXECUTIVE SUMMARY
Registration-related billing errors dropped by more than 30% as a result of an organization-wide focus on reducing accounts receivable days at Stanford Children’s Health. These successful approaches were used:
- Accountability for registration and billing accuracy was moved to the registrars who initially captured the data.
- Correct diagnoses and procedures were obtained to calculate accurate estimates of insurance and patient liability.
- Exactly what insurance will pay was determined earlier in the process.
As if there aren’t already enough roadblocks to obtaining authorizations, payers are now requiring unrealistic timeframes to review these requests.
“Most payers are now requesting at least 10 to 14 days to review a case prior to rendering an authorization,” reports Stacy Hutchison-Neale, CRCR, supervisor of the hospital pre-authorization department at Nemours Alfred. I. DuPont Hospital for Children in Wilmington, DE.
“In a perfect world, this timeframe would be fine. But we are working with sick children and the demands of service to be rendered, sometimes the same day,” says Hutchinson-Neale. The department takes these steps when facing time crunches with authorizations:
• Patient access keeps providers informed at all steps of the authorization process so there are no surprises.
When patient access receives a request within a 10-day timeframe for non-participating insurance companies, or within a five-day timeframe for participating insurance companies, staff members immediately notify the provider that the authorization request has been received and worked but is pending.
• Patient access asks if the service can be postponed, which allows the insurance company time to render a determination on the case.
“If the service cannot be delayed, then we submit a full detailed request to administration to review the request for services,” says Hutchinson-Neale.
Requests then are reviewed for medical necessity. Lisa Adkins, MSN, RN, CPNP, CRCR, director of patient authorization, says, “I look at the child’s previous clinic visits, imaging and lab studies, and/or hospital documentation to determine the medical urgency of the request.” For example, she determines if the child is in pain, if the child will suffer specific consequences if the service is delayed, and whether the diagnosis and treatment plan fits with the requested service.
“If the documentation is unclear, or I believe more information is required, I will reach out to the ordering provider,” says Adkins.
In some cases, patient access is able to justify that the authorization is required in a shorter timeframe than the payer requires, when the clinical information demonstrates the need to have the procedure, test, or admission initiated as soon as possible. “This may mean a peer-to-peer conversation with the plan’s medical director or a letter of medical necessity,” says Adkins.
• The authorization specialists, even if they have administrative approval from the hospital, continue to work with the insurance company to ensure that the approval is secured.
Hutchinson-Neale says, “We contact the payers for status of the authorization request every two days, for routine cases, and daily for pressing cases.”
She is noticing longer hold times when making calls to payers. “Call times range from 15 to 45 minutes, if not more, depending on the cover-age,” she says. “Some plans with longer wait times can have us tangled in a case for more than an hour with hold time.”
If all needed documentation from the provider is not readily available, the process of follow-up calls can last for days. Adkins says, “We encourage our providers to ensure that all medical justification for a case is notated in the chart for easy access.” This justification includes the medical reason for the procedure, medication dosages, instructions for infusions, and the plan of care.
Hutchison-Neale says, “When the information is readily available in the chart, it alleviates the amount of callbacks the physician authorization team needs to make to the insurance company.”
ACCESS IS "IN THE MIDDLE"
Some payers are taking up to 14 days to respond to authorization requests, reports Lynn Arrington, CHAM, director of insurance verification at Arlington-based Texas Health Resources.
“A couple of years ago, payers weren’t so driven on timeframes as they are now,” Arrington says. “The payer determines the timeframe. If the payer has a 14-day timeframe, we are at their mercy.” Physicians often want to schedule patients within two or three days, but insurers slow the process down. “They are looking to make sure the patient really needs the procedure, and the doctor wants to hurry up and schedule it,” says Arrington. “We are in the middle.”
The department created a spreadsheet listing insurance verification precertification turnaround times for high-tech radiology procedures by payer, and it shared the spreadsheet with providers’ offices and the scheduling department. [The spreadsheet used by the department is included with the online issue. For assistance accessing your online subscription, contact customer service at [email protected] or (800) 688-2421.]
“Communication between scheduling and the providers’ offices is key,” says Arrington. Payers want detailed clinical information and peer-to-peers, which further complicates the process. “After they receive all of the required information, that’s when the clock starts,” she says.
To add complications, some payers are specifying that only the physician’s office can start the authorization process. “The payer will even go so far as to include this information in our contracts that our managed care department negotiates with them,” says Arrington.
Schedulers use this scripting when talking with providers’ offices: “Have you obtained an authorization for this procedure? What is the authorization number? If authorization is needed, will you be obtaining that for the facility as well?”
Some patients opt to reschedule if the authorization isn’t in place. If the patient chooses to go forward regardless, he or she is asked to sign a non-coverage letter. “If we are not confidant that an account is going to be financially secure with an auth prior to services, then we are ultimately liable for the account,” Arrington explains. (See related story in this issue on “no auth” claims denials.)
SOURCES
- Lisa Adkins, MSN, RN, CPNP, CRCR, Director, Patient Authorization, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE. Phone: (302) 651-4548. Fax: (302) 298-7290. Email: [email protected].
- Lynn Arrington, CHAM, Director, Insurance Verification, Texas Health Resources, Arlington. Phone: (682) 236-1712. Fax: (682) 236-1721. Email: [email protected].
- Stacy Hutchison-Neale, CRCR, Supervisor, Hospital Pre-Authorization Department, Nemours Alfred. I. DuPont Hospital for Children, Wilmington, DE. Phone: (302) 651-5184. Email: [email protected].
