Payer auth requirements shouldn't blindside you

Prevent needless claims denials

Payers are asking for more preauthorizations, even for services that previously didn't require them, reports Connie Campbell, director of patient access of Mercy Medical Center in Oshkosh, WI.

"We need authorization for select outpatient procedures, which I am sure will also turn to all outpatient procedures," Campbell says. "Even some of the Medicaid products are starting to require authorizations, where before they did not."

Magnetic resonance imaging (MRI), ultrasound, nuclear medicine, and CT scans require authorization, she says. Authorizations also are needed for durable medical equipment (DME), medications, hospital stays, physical therapy, radiology, behavioral health, the pain clinic, and all inpatient surgeries, she adds.

Registrars find it increasingly difficult to keep up with all of the different insurance company requirements, says Campbell. "We have no software to easily pop up with what specifically is needed for what is ordered," she says. "There is no way to easily translate the CPT and ICD-9 codes for physicians so they can see what is needed."

Needless denials occur as a result of getting the wrong authorization or failing to obtain one that is required, says Campbell. "We considered forming a large authorization department to deal with the new requirements," she says. "But since that project was turning to be out too immense, we decided to focus on obtaining authorizations for the high-dollar radiology procedures."

Otherwise, says Campbell, each office or specialty is responsible for staying current and obtaining the necessary authorizations. "We did start putting the requirements on spreadsheets," she says. "We also try to build in as many cues as we can into our computer systems."

Identify mismatches

At Valley Health System in Ridgewood, NJ, the information services (IS) department built a tracking system so staff can see what pieces of the pre-registration function are outstanding at any point in time, says Maura Corvino, MSOL, RN, CEN, assistant vice president for emergency services and patient access.

The missing pieces might be data from the physician necessary for case day or pre-authorization because the case was scheduled too far in advance to obtain it from the payer, she says.

"Another customization our IS department built allows us to compare the planned disposition for the patient with the requirements by the insurance company," says Corvino. "If there is a mismatch, we can rectify it before the patient arrives." (See more on Valley Health's system, below. Also, see related stories on obtaining more authorizations, and timeframe for obtaining authorizations, below.)


For more information on payer authorization requirements, contact:

  • Connie Campbell, Mercy Medical Center, Oshkosh, WI. Phone: (920) 312-0002. E-mail:
  • Maura Corvino, MSOL, RN, CEN, Valley Health System, Ridgewood, NJ. Phone: (201) 447-8301. Fax: (201) 251-3467. E-mail:
  • Susan Sigler, Valley Health System, Ridgewood, NJ. Phone: (201) 447-8000 Ext. 2778. Fax: (201) 251-3467. E-mail:

Last-minute auths die: Most are 20 days out

At Valley Health System in Ridgewood, NJ, patient access staff perform pre-registration up to 20 business days before most scheduled procedures, reports Maura Corvino, MSOL, RN, CEN, assistant vice president for emergency services and patient access.

"We make sure that the physician's intention matches what the validation is," says Corvino. "Four days before case day, we are really working closely on that group of people."

Certain procedures are mandated by insurers as "inpatient only," explains Corvino, but the physicians might not think the admission is necessary. When this situation happens, the physician is notified so he or she can write the appropriate orders well before case day, she explains.

The new process means that more OR procedures are starting on time, says Corvino. "More on-time starts for the physicians will probably open up ORs for a few more cases," she adds. "That has the potential to bring us some more revenue as well."

Many claims denials were occurring because authorizations weren't obtained upfront and were obtained only after the patient was in the hospital, explains Susan Sigler, supervisor of Valley Health System's patient access center. "That was a big driver of this change," Sigler says. "We had to go back and make the corrections and get the denials overturned."

This system meant a lot of manual work for the case management department that is no longer necessary, says Sigler. "In moving that work up to the front end, we expect to see a really significant drop in denials," she says. "By ensuring the right disposition for a given procedure, whether admit, observation, or discharge, everybody is on the same page with the insurance company."

More data needed

If the procedure code doesn't match the diagnosis code, registrars have to get more information from the physician, says Sigler.

"The physician is very knowledgeable about the plan of care and the patient's condition, but sometimes not so detailed when they give the diagnosis code," she says. "Sometimes it takes a little bit more data than what we have initially to get the authorization."

Previously, there wasn't time for this back-and-forth dialog, which meant that the case was delayed or the patients were left with a bill that they didn't anticipate, says Sigler. Corvino says, "Because this is medicine, a diagnosis code may change. If that's the case, we can go back and change it while the patient is still here, rather than getting that denial and going back for the rebill."

Sigler expects patients will be more satisfied with the new process. "If we are able to do all of this in a manner that streamlines things for the patient, hopefully that will be reflected in our hospital patient satisfaction scores," she says. "With new emphasis on the HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems], that could impact how we are reimbursed going forward."

Revamped role to mean fewer denials

At Valley Health System in Ridgewood, NJ, a major goals are to obtain more authorizations, says Maura Corvino, MSOL, RN, CEN, assistant vice president for emergency services and patient access.

A new Patient Access Center will help with this goal by centralizing Valley Health's registration, Corvino reports. "We have initiated some new software and reallocated resources," she says. "We expect to get a very low error rate and a very good return on investment."

While registration was decentralized almost two decades ago to make registration more convenient for patients, this decentralization no longer made sense as the patient access role expanded says Susan Sigler, supervisor of Valley Health System's patient access center. "The kind of work that was being added to the job of the business associates was quite varied and very unfocused," Sigler says. The business associates perform a wide variety of tasks, only one of which is registration, she explains.

"The business associates wear many hats," says Sigler. "Whenever there was a new responsibility that did not fit cleanly into another role, it was absorbed by the business associates on the individual units."

While that served all the individual units very well, says Sigler, it made it challenging for the individual business associates to maintain the quality of their registrations. Errors occurred that resulted in inaccurate billing, she explains. "This led to more back office work to correct and edit, and the need for re-billing," Sigler says. "It ultimately decreased patient satisfaction, as they dealt with both the insurance company and the hospital billing office to rectify the inaccurate bill."

Designated role

While endoscopy, the emergency department, and diagnostic imaging were high in registrations per business associate, the volume of registrations per business associate was low in some units, says Sigler. Because those employees did registrations only rarely, they had trouble keeping up with all of the different payer requirements, she explains.

"It became a real challenge to provide that education in a manner that didn't disrupt the rest of their duties," she says.

Corvino says that by having patient access staff pre-register patients with scheduled procedures and obtain authorizations, "everybody there is an expert in these work activities. They are marching through a systematic process of validating and checking."

Now, members of the patient access staff "huddle" each day to talk about the next day's cases with staff from the patient care areas. "We make sure that we are crystal clear that everybody's covered," says Corvino. "If we do all this work upfront, we won't be talking over the patient on the stretcher about the authorization that we didn't get. We'll be focused on their care."