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According to Memphis-based Methodist LeBonheur Healthcare’s policy, if a physician sends a patient to a facility for an outpatient test, the test is still done, even if the precertification is not yet in place.
“It’s part of the service we are trying to provide for our patients and our physicians,” says Vicki Boyd, director of the hospital’s centralized services division and former director of patient access services. “But if it’s 4 p.m. on a Friday and the plan won’t retroactively give the precert, it’s going to be written off.”
Here are some changes the department has made to prevent clinically related denials:
In some cases, staff members scramble to obtain required authorizations before the close of business. “We make sure to staff appropriately to meet those timeframes,” says Boyd. “We have a committed team of precert specialists who will do whatever it takes to get that precert secured.”
Staff members sometimes stay later, come in earlier, or work on a Saturday or holiday. “The good of the patient always comes first,” says Boyd. “But without appropriate reimbursement, we could not stay in business to provide that service.”
Increasingly, payers are requiring authorizations for specific medications or for implants used during a surgical procedure. To prevent denials, employees now attempt to obtain approval before surgery for items that potentially could be used.
“We now get the authorizations on the ‘possibles,’ so these will be covered if they’re used,” says Janice “Mae” Williams, manager of precertification at the hospital’s Centralized Services Division. “We also instructed the scheduling team that if any implant is involved, to name it on the front end.”
Payer reps sometimes tell the precertification specialist that no precertification is required for a particular service. “What they don’t tell you is that it’s not necessarily a covered benefit,” says Williams.
For example, nutrition is not necessarily a covered benefit for a chemotherapy patient, even though it’s part of the patient’s plan of care. “The key is not to have the patient or the facility surprised on the back end,” says Williams.
Prior to giving approval, the patient’s carrier might ask the physician to do a peer-to-peer conversation if a high-dollar claim shows the potential of being denied for non-substantiated clinical reasons. “Or the provider can request a peer-peer to push the procedure through,” says Williams. “In talking to another clinician, they may decide that the care is appropriate and approve it.”
In some cases, precertification was obtained for the patient’s surgery, but additional procedures were done during the surgery that weren’t anticipated. This results in the entire claim being denied.
Boyd says, “If you miss a couple of those, it can be devastating to your bottom line.”
Quick notification that additional procedures were done avoids many denials. However, some have slipped through because the surgical team didn’t notify case management in a timely manner. “We found that all of those occurred on the weekend,” says Boyd. “We are trying to bridge that communication gap.”
“That gives us the next four hours to get the precertification,” says Boyd. “It also lets case management, surgery, and patient access know that the surgery may need to be moved to later in the day.”