Payers zeroing in on clinical necessity

Strong verification process needed

Brian A. Todd, CHAM, manager of patient access staff development and training at Lourdes Health System in Camden, NJ, is seeing additional restrictions coming from companies that are doing clinical necessity checking.

"We're seeing this mostly in the radiology modality, but it can encompass other departments as well, such as outpatient cardiac testing," says Todd.

Some of the clinical necessity checking companies are not using "groupers," in which a group of similar procedures is covered under the umbrella of one authorization, says Todd, so the importance of obtaining the correct procedure requested at the time of scheduling has become crucial.

Previously, a CT scan of the abdomen with contrast or without contrast would have been considered in the same group, but this situation is no longer the case. "We're now finding we must be specific, even down to the use of contrast," says Todd. "The clinical necessity checking companies are zoning in on specifics."

To minimize costs and mitigate their insurance risk, payers are seeking to ensure their members are getting the tests they deem necessary, says Todd. "They are, in a sense, guiding the referring physicians' hands into a protocol of what studies they feel should and should not be administered, based on the diagnosis and supporting health factors," he says.

This change means that patient access needs to work more closely with provider's offices, says Todd, who adds that the best method he's found is to build relationships with insurance verification staff at physician offices. "That collaboration helps them to realize that they are in the same boat, with a common goal of ultimately getting the patient serviced," he says.

Denials might occur due to the absence of a referral or authorization prior to testing being done or out-of-network limitations, says Todd. "These can be combated with a strong insurance verification process, as close to the point of scheduling the procedure as possible," he says.

If a claim is denied because additional procedures are done while the patient already is in the department, add-on procedures that manage to bypass the established process, or a patient's pre-existing conditions, these denials are more difficult to manage, acknowledges Todd. This is that point at which the cooperation of the ancillary department and the physician's office becomes essential, he explains. "The gamble here is that the add-on testing will be approved at some point by the ones doing the clinical necessity checking," Todd says. "You want to make sure the process to get the authorization is started prior to the actual service being performed."