Stop `no auth’ denials with new processes - Access is struggling with new payer requirements
Executive Summary
Payers are requiring authorizations for many additional procedures, which results in increased claims denials and dissatisfied patients. Patient access departments are making these changes:
- sending correct information to payers to show the medical need;
- asking payers for the best way to submit authorization requests;
- Contacting Ordering Physicians To Learn The Reason For Tests.
Many payers are requiring authorizations for services that have not needed it in the past, reports Aaron Robison, CHAA, a patient coordinator and former financial advocate at University of Utah Health Care in Salt Lake City.
"Our department has been working tirelessly on our prior authorizations, to combat the rise in needed approvals," he says.
Insurance companies are updating their medical policies to combat waste or unnecessary treatments, notes Robison. "Though this is a good idea, it can place great stress on our team," he says. "We need to make sure that everything that is done for our patients has an authorization in place if needed."
This situation means continually calling insurance companies or researching the payer’s medical policies online. Both of these tasks are time-consuming, says Robison, but "we cannot afford to miss obtaining the approval. We cannot bill the patient for procedures that we failed to get authorized."
Patient access leaders at Ann & Robert H. Lurie Children’s Hospital of Chicago are seeing more payers requiring pre-certification for tests such as echocardiograms, which traditionally have not required pre-certification, reports Lisa Lenz, CPC, CMPE, administrator of the physician revenue cycle.
"Payers are constantly adding to the types of procedures that need pre-certification," she says. Patient access staff subscribe to a service that monitors payer websites daily to keep up on the changing authorization requirements (Payer Alerts service, Experian Healthcare, Maple Grove, MN).
Due to increased authorization requirements, health benefit associates at Castle Rock (CO) Adventist Hospital check online or call payers for all high-tech radiology procedures, says Jeryl Wikoff, patient access manager. Here are other changes that the department made:
- Staff members sign up for emails from payer websites, so they are notified when updates are made.
- Staff members work closely with practice managers so they know that a referral is required.
- Staff members are kept informed of payer changes by the business office.
To keep up with new authorization requirements, University of Utah’s patient access leaders created additional work queues in the hospital’s Epic system so accounts can be tracked and monitored while they are waiting for authorizations. "If an account hits a pre-auth work queue, then we know to start the authorization process for the ordered service or procedure," says Robison. The work queues give staff the ability to run reports to see how many accounts were not authorized or were missed for some reason.
"The trick is to stay ahead of the curve as best as possible," says Robison. "Without knowing when an insurance company will update their policies, however, it is difficult to do so."
Charges written off
Depending on which tests or services are denied due to no authorization, hundreds to thousands of reimbursement dollars can be lost, Robison emphasizes.
"If it was cancer-related and a high-dollar procedure, the loss could easily be close to $100,000 or higher," he adds. For example, if a chemotherapy regimen is given without prior authorization, and the insurance company does not allow for retro-authorizations, a sizable amount of money would have to be written off.
In some cases, charges are written off that would otherwise have been covered.
"Most insurance contracts do not allow patients to be billed for non-authorized services," explains Robison. "This means that we have no choice but to take the hit to our revenue."
Denials are appealed
About 90% of "no-auth" denials are successfully appealed at University of Utah. "We submit retro-auths and appeal denials vigilantly," says Robison.
Generally, most major insurance companies accept appeals of denials due to no prior authorization on file, he notes, but that acceptance doesn’t mean the denial will be overturned. With this position in mind, every denial due to lack of a pre-authorization is taken seriously.
"If the clinical team performs services without notifying us first, we then communicate to them the need to always go through patient access first, unless the services are needed for emergent reasons," says Robison. (See related stories on communication with clinical areas, below, and additional information required by payers)
- Lisa Lenz, CPC, CMPE, Administrator, Physician Revenue Cycle, Ann & Robert H. Lurie Children’s Hospital. Phone: (312) 227-7121. Fax: (312) 227-9150. Email: [email protected].
- Aaron Robison, CHAA, Patient Coordinator, University of Utah Health Care, Salt Lake City. Phone: (801) 587-6014. Fax: (801) 581-2244. Email: [email protected].
- Jeryl Wikoff, Patient Access Manager, Castle Rock (CO) Adventist Hospital. Email: [email protected].
