Precert staff don’t take ‘no’ for an answer
Precert staff don’t take no’ for an answer
We stop at nothing,’ director says
A precertification program at University of California at San Francisco (UCSF) Stanford Healthcare is turning around — in advance of service — 60% of all denials of coverage that come through the department, says Sherry Kraft, assistant director of admitting/precertification.
In a 16-month period, the program’s six staff members, including two registered nurses, brought in $1.25 million in revenue that otherwise would have been lost, while guaranteeing that patients involved would receive the best possible care, adds Dorothy Marian, RN, one of the two precertification nurses.
"We stop at nothing," Kraft says. That can mean, she adds, getting physicians on the phone to explain a procedure, faxing the review organization clinical articles on the latest treatments, or, in one recent case, tracking down an insurance salesman to get information backing up a patient’s claim.
The critical success factor, she says, is the trust established between the precertification staff and the offices of the 100 physicians who are part of the UCSF Stanford Healthcare system. The key to that trust is timely and consistent communication, Kraft adds. "We send the physician’s office a letter about what has happened, and we also communicate verbally. We keep them in the loop."
Clinical expertise a must
The clinical expertise of the precertification staff is crucial to the program’s success, she says. Of the four non-nurses, Marian points out, two have graduated from nursing school but have not yet taken state licensing exams.
"We’re very proud of the fact that we’ve been able to appeal denials prospectively," Kraft says. "If the review organization has denied access, but we know because of the complexity of the case it should be handled here, we will work with the physician’s office and do what it takes to get the [denial of the] case overturned. [At other facilities], they might just accept the denial, and the patient would not get the care."
The typical precertification process, Marian explains, goes as follows:
1. "The physician clinics will fax us the demographics and any clinical information on a case. I call the insurance company and make sure the benefits are in place, and then I call the review company and present the clinical information. Sometimes I reverse the calls, depending on how complex the problem will be. Then I create the account in the computer and talk to the patient to make sure he or she doesn’t have information we don’t have, like the fact that the insurance company has changed. Then I clear it in the system, and the patient is ready to come in."
2. The precertification employees have a clinical database available to them, and the non-nurses use the RNs as resources on more complex cases, Marian notes. Knowing the kind of information review organizations typically ask for is much of the battle, she adds. "If it’s cancer, they want to know how it was diagnosed. If it’s heart surgery, they want to know what the cath [cardiac catheterization] report showed. You don’t need a whole lot of clinical information once you realize what they want."
Getting the go-ahead
At UCSF Stanford, all elective inpatient and outpatient procedures must be financially cleared, Marian says. "If not, [the case] is delayed or postponed or referred to a financial counselor. We keep the physicians’ offices informed that there are problems."
The system works best if the precertification staff are aware of cases two to four weeks in advance of service, she says. "We are working two to three weeks out most of the time, but sometimes it’s five days, or the next day." In a recent case of an abdominal aneurism repair, Marian notes, the final OK was obtained the night before surgery.
In that case, the vascular surgeon, who was with a health plan outside the UCSF Stanford system, believed a stent repair was the appro priate treatment, she says. Request for treatment at UCSF Stanford was denied by the patient’s HMO, which maintained the treatment should be done in-plan, Marian adds. "No one in that plan could do it, but they still denied service at Stanford. We worked with the outside vascular surgeon and a physician from the review organization to turn that [denial] around."
When a gastric bypass for obesity was initially denied as noncovered, "we indicated clinical co-morbidities, went to the medical director of the insurance company, and he turned it around," she says.
In another case, the staff turned around a denial involving a so-called pre-existing condition, Marian explains. "The patient stated he had been diagnosed on a particular date, after the policy was bought, but the insurance company wouldn’t authorize the treatment. Supposedly the information had been faxed to them, but it never got through."
Accountable for complete episode
Until it’s proven otherwise, the insurance company assumes a condition is pre-existing, adds Marian. "Because the patient had not had insurance prior to this, there was no rollover’ or state law that would protect him. He was a young man with metastatic cancer and really needed the treatment, which would have cost him about $30,000.
"We called the person who sold the insurance policy," Marian says. "He went to the physician’s office, got the records, and faxed them to the insurance company to prove that the condition came up after the patient was enrolled."
Formerly a part of the social work and case management department, the nine-year-old precertification program merged into the admitting department a little more than a year ago, Kraft notes, soon after Stanford merged with UCSF Medical Center in November 1997. Stanford had the original program, which is now being piloted with one nurse at the UCSF Stanford north campus facility, she adds.
Recently, the registration workflow was changed, Kraft points out. "It used to be that the precertification staff just dealt with clinical justification. Now they’re doing all the preregistration, verification of insurance eligibility, plus the precertification. Because they don’t hand off the case, they are accountable for the complete episode."
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