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Even if patient access employees follow all the necessary steps to obtain an authorization for a procedure, the payer might still want to talk to another person before granting the authorization: the patient’s physician.
"Our physicians are engaging in more peer-to-peer conversations with payers than they ever have in the past," reports Pamela D. Scott, MBA, revenue cycle administrator at Genesis Health System in Davenport, IA. "This means patient access, case management, and physician advisors need to be more closely aligned." (See related story, p. 127, on other trends resulting in physicians getting more involved in avoiding claims denials.)
More and more payers are requiring peer-to-peer justification for services, reports Kasandrah Garnes, MBA, senior director of patient access at Thomas Jefferson University Hospitals in Philadelphia. However, the Outpatient Cardiac Imaging service team is seeing about 40% fewer "peer-to-peer" requests because of these approaches:
Physicians, nurses, and patient access representatives review the authorization process at integrated team meetings.
"The team has spent time learning from previous denials," Garnes says. "As the team grows in knowledge, they can better anticipate which types of tests tend to be denied if additional medical documentation is not submitted."
For example, patient access staff learned how payers consider the patient’s age and medical history with stress echocardiograms. Patty Huffnagle, patient access supervisor, says, "Insurance companies may require a stress EKG before authorizing an echo for our younger patients with no cardiac history and with new symptoms."
For this reason, staff members always submit the current clinical note and EKG when requesting authorization for such patients to have stress echocardiograms. Likewise, patient access staff members learned that certain payers will approve a stress echocardiogram every three years in an asymptomatic patient with a previous echocardiogram showing mild regurgitation. "However, if a patient’s regurgitation was moderate to severe, the echo would be approved annually," says Huffnagle.
Nurses answer questions that members of the patient access team have, when there is a gap in clinical knowledge.
As the patient access team members learn more about diseases of the heart, they have a better understanding of the physician notes and the plan of treatment. "This proactive communication has contributed to a decline in peer-to-peer requirements for authorizations," says Garnes.
Technicians and nurses have given in-services to the patient access team, for example, to explain how the heart functions when the patient has a certain diagnosis. "When a clinician has not detailed which specific abnormalities were presented from an EKG, we will ask for that detail," Garnes adds.
The few peer-to-peer requests that are received are electronically submitted to physicians. "The physicians do an excellent job responding to these alerts timely," says Garnes. "They understand the important role that they play in securing these authorizations."
Teresa L. Brooks, Senior Director, Patient Access, Conifer Health Solutions, Detroit. Phone: (313) 578-3675. E-mail firstname.lastname@example.org.
Kasandrah Garnes, MBA, Senior Director, Patient Access, Thomas Jefferson University Hospitals, Philadelphia. Phone: (215) 955-2757. Email: Kasandrah.Garnes@jefferson.edu.
Pamela D. Scott, MBA, Revenue Cycle Administrator, Genesis Health System, Davenport, IA. Phone: (563) 421-1990. Email: ScottP@genesishealth.com.