EXECUTIVE SUMMARY
Payers are requiring more time to review authorization requests, which causes patient access to reschedule procedures in some cases.
- Alert providers of new time requirements.
- Create a spreadsheet listing timeframes for specific procedures.
- Inform patients if the authorization is not yet in place.
“No auth” denials make up about a third of total claims denials at Nemours Alfred. I. DuPont Hospital for Children in Wilmington, DE, estimates Lisa Adkins, MSN, RN, CPNP, CRCR, director of patient authorization.
Reasons for denials include that the service is experimental, that the service did not meet medical necessity, or that the service required a prior authorization. About half of denials are overturned after they’re appealed, however, says Adkins.
Authorization specialists copy and paste all responses regarding the authorization into the electronic medical record, including diagnosis and procedure codes and eligibility information. Stacy Hutchison-Neale, CRCR, supervisor of the hospital pre-authorization department, says, “This helps the central business office and the utilization management team to appeal claims if need be, to get the denial overturned.”
If the response was received by phone, staff members obtain the call’s reference number so the call can be reviewed, if necessary. In some cases, they’ve found that the payer representative approved the case to move forward or gave inaccurate information. “We have noticed there are often discrepancies from what the provider’s website states about authorization requirements compared to what a representative says,” notes Hutchison-Neale.
Many times, payer reps state, sometimes incorrectly, that no authorization is required for services. “Even though we are provided a reference number for the call, when the claim is submitted, we may get a denial for the request because it actually needed an authorization,” says Hutchison-Neale.
The denials always are appealed on the back end, often successfully, but payment is delayed. “Lag time with the provider websites has increased,” Hutchison-Neale says. “If we notice that an issue is going on with the website, there is never an easy fix.” It can take weeks or even months for it to be corrected. “This means that the authorization team has to troubleshoot and do work-arounds on a daily basis,” says Hutchison-Neale.
Patient access is taking extra time to review payer clinical policy guidelines for medical and pharmacy. “When calling insurance companies for pharmacy-related authorizations, there is always a catch,” says Hutchison-Neale.
Many times, patient access is told no authorization is required for a medication, even when all codes are provided. Once the claim has been processed, however, the story changes. “We may get notification that there was a denial because it needed to come from a specialty drug pharmacy, which requires a separate authorization,” says Hutchison-Neale.
The authorization team came up with a new process to avoid these denials. “Not only do we obtain authorizations through the medical insurance company; we also obtain authorizations through the specialty drug company for the medication,” says Hutchison-Neale. Patient access reviews payers’ clinical guidelines to ensure that medication is billable through the medical policy and not required through the specialty pharmacy.
“The insurance company does not always provide that information,” explains Hutchison-Neale. “If the medical policy does not outline the process for us, we are at the mercy of the insurance rep.”
