EXECUTIVE SUMMARY
Payers may deny claims if a different procedure or additional procedure is done after the initial authorization was obtained. Patient access leaders at United Regional obtain 99.8% of all authorizations and use these strategies:
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obtaining authorization for a range of procedures or medications;
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asking payers to update the CPT codes on the authorization;
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contacting office managers if additional procedures often are done with a particular physician, so those CPT codes are included on future authorizations.
When a physician orders a procedure to be performed in a surgical setting at Birmingham, AL-based UAB Hospital, patient access staff start the process of obtaining required authorizations.
Once the physician begins the approved surgical procedure, however, there might be changes. “There are sometimes instances where the expected procedure to be performed has to be modified based on findings during the actual surgery,” says patient access director Lee Patillo, CHAM.
Even with an effective upfront process, there are instances when a procedure that was not scheduled originally is added on after the patient arrives for service. Amanda Taylor, director of patient access at United Regional in Wichita Falls, TX, says, “Some examples where we see this occur most frequently include diagnostic studies, infusion medications, and surgical procedures,” says Taylor.
Many insurances won’t allow retroactive authorizations. This process means that the authorization has to be obtained prior to a service being performed. “This is an area that we have placed a lot of focus on,” says Taylor. “We successfully obtain approximately 99.8% of all authorizations required.”
Some payers allow a range of authorizations, while others will authorize only a single CPT code. “It is important to investigate this before the service is performed,” says Taylor.
As soon as they’re notified that additional procedures will be performed, patient access staff members begin working immediately to obtain required authorizations.
“Some insurance carriers allow us to contact them directly to update the CPT codes on the authorization,” says Taylor. “Others require the physician to make those changes.”
Patient access staff members can obtain authorizations only for services they are aware of, emphasizes Taylor. Here are some effective processes to avoid “no auth” claim denials:
• Diagnostic tests.
Diagnostic studies, such as CTs or MRIs, are the tests that change most frequently after being scheduled.
“This is normally due to a change in the contrast order,” says Taylor. “To make the process work, we rely heavily on radiology [staff] to make us aware of changes prior to the test being performed.”
These steps are taken:
— Patient access staff worked closely with radiology staff on the process.
— Patient access staff provided radiology with a list of payers that do not require authorizations.
“Radiology knows they do not need to reach out to us on those payers,” says Taylor.
— Patient access staff provided the radiology staff with a direct contact on the hospital’s insurance verification team to call when a change to a procedure occurs.
— Insurance verifiers review the procedure and the patient’s insurance to determine the authorization requirements.
“We either inform the department that it is OK to proceed, or we ask that they give us time to obtain an authorization,” says Taylor.
• Medications.
Patient access staff members have found that orders for medication infusions sometimes are substituted for different medications by the patient’s physician. To avoid claims denials when this happens, “we request an authorization for a range of medications to ensure, regardless of the medication provided, we will have the needed authorization in place,” says Taylor.
• Surgical procedures.
“This is an area that we look at trending information,” says Taylor. For example, patient access staff members sometimes notice that a particular physician frequently performs more than one procedure, even if only one procedure was scheduled.
“In those instances, it is best to look at specific detail, such as the type of procedures and how frequently it occurs,” says Taylor. Next, patient access staff members work with the physician’s office to develop a plan. “We reach out to the office manager and gain a better understanding of why we are frequently seeing changes,” says Taylor. In some cases, the additional CPT codes can be included in future authorizations upfront. “It takes a multidisciplinary approach to effectively manage denials due to lack of authorization,” emphasizes Taylor.
At UAB Hospital, utilization managers work with payers to obtain authorizations for any additional procedures that are performed. “Once the updated authorization is obtained, the utilization manager updates the authorization in the hospital billing system,” says Patillo. “This prevents a denial.”
