Missing clinical info can mean no authorization

Martin Memorial Health Systems in Stuart, FL, reports an increase in authorization requirements for inpatient and outpatient accounts.

Authorizations can be time-consuming when they must be obtained and verified via telephone, says Carol Plato Nicosia, CHFP, CPAM, MBA, administrative director of corporate business services. "The physician is required to start the authorization process, in most cases," says Nicosia. "Even if the physician obtains an authorization number, hospitals are required to verify the number is correct and, in some cases, activate it."

For this reason, excellent communication between the authorization area, the clinical areas, the central business office, and the ordering physician becomes critically important, she says. Here are some specific challenges:

• Obtaining authorizations for exactly what outpatient test or procedure is being done.

"This sounds easier than it is," Nicosia says. "In many straightforward cases, it may be a simple match, but many cases get complicated. These complications may require re-work after the service is complete."

An authorization might be obtained for a colonoscopy, she explains, but if polyps are removed during the procedure, the billing CPT code will not match a straightforward colonoscopy, which results in a claim denial. "Therefore, if it is likely that polyps will be removed, the authorization should be obtained accordingly," says Nicosia. If the correct authorization is not obtained prior to the procedure, a second call to the payer is required to explain that the procedure changed and needs to be updated in their system, she adds.

• Obtaining authorizations for complex diagnostic services, including cardiac procedures and radiologic interventional procedures.

"These cases have physicians involved during the procedure, and changes may be made to the original order during the actual procedure," says Nicosia. If they do, the authorization would not match and would need to be updated in order to prevent a denial, she adds.

• Getting the authorization to match the service type.

At the time of admission, there often isn't enough clinical information to determine whether an inpatient or observation authorization will be needed, Nicosia says. "Continuous follow-up is required in these cases," she says. "Getting the service type correct the first time helps to prevent denials after claims are sent."