Complex authorizations offer expensive mistakes

While some authorizations are straightforward, others can be complex and result in claims denials, according to Alicia Alampi, manager of patient access at St. Joseph's Hospital in Syracuse, NY.

"We have seen an increase in the number of authorizations needing pre-certification," she reports.

Elective radiological procedures now require authorizations, says Alampi. "Patients who previously had Medicare and straight Medicaid who are moving to HMO plans, and patients being converted to inpatient status after their scheduled procedures, cause an increase in the number of authorizations we need to obtain," she says.

More and more, insurance companies are asking for ICD-9 codes, adds Alampi. "We are not able to provide these at the time of notification, but the staff does have a narrative diagnosis," she says. Physician offices might fail to notify insurance companies prior to procedures, and payer web sites aren't always up to date, she adds.

Time-consuming process

Central DuPage Hospital in Winfield, IL, is experiencing a 10% growth in its diagnostic imaging service line, and many of these procedures require preauthorization, says Debbie Milke-Wurster, RHIT, revenue cycle manager.

"Processes are always an issue," says Milke-Wurster, giving the example of how the need for pre-certification appears on work lists. "If something is coded wrong or put in a wrong category, it might not be flagged without a manual review. From a clinical standpoint, an additional view or slight modification could be required."

The insurance company might deny the claim if this information wasn't provided before service, says Milke-Wurster. "Additionally, our payer mix is now representing more PPO and HMO product lines, which require pre-authorization," she says. While Medicare and Medicaid currently do not require pre-authorization, PPOs and HMOs are moving more toward online electronic verification, says Milke-Wurster. "This is good, as it gives a written trail and takes less time to complete the task," she says.

A challenging process

The number of insurance plans and the variety of methods to obtain the pre-authorization, whether electronic, phone, or contacting the patient's physician, make this process very challenging, says Milke-Wurster. "In addition, clinical information is often needed, which can slow down the process," she says. "While more insurance companies are offering online solutions, there are still a significant number of times when a phone call is required. Not all insurance companies provide an online solution."

Communication with the physician offices is essential, says Milke-Wurster, as there is required information from both sides. Staff members use a variety of tools, such as a list generated from the system that is more efficient than a manual paper trail, to ensure the pre-authorization is obtained. "This list can be shared amongst users and is real time," she says. "Management can monitor this at regular intervals."

To avoid denials due to new payer requirements, Alampi says that "communication is the key strategy."

Patient access managers inform the verification staff of all updates and changes as soon as these are received from the managed care and patient accounting departments, says Alampi. "We also have an 'Access Communiqué' that is sent out weekly, with all insurance updates to the multiple access points in our network," she says.

Alampi created internal department work queues that allow staff to write the rules for the verification staff. "We also use web sites and an eligibility system, including reports that have been created as a back up," she says. "We want to ensure that nothing falls through the cracks."

Sources

For more information on processes for obtaining authorizations, contact;

Alicia Alampi, Manager of Patient Access, St. Joseph's Hospital, Syracuse, NY. Phone: (315) 448-5384. E-mail: Alicia.Alampi@sjhsyr.org.

Debbie Milke-Wurster, RHIT, Revenue Cycle Manager, Central DuPage Hospital, Winfield, IL. Phone: (630) 933-3038. E-mail: debbie_milke-wurster@cdh.org.

Carol Plato Nicosia, CHFP, CPAM, MBA, Administrative Director, Corporate Business Services, Martin Memorial Health Systems, Stuart, FL. Phone: (772) 223-5945, ext. 5656. Fax: (772) 223-5622. E-mail: cplatonicosia@mmhs-fla.org.