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Janice “Mae” Williams, manager of precertification at Memphis, TN-based Methodist Le Bonheur Healthcare’s Centralized Services Division, recalls having a “wow” moment during the first week of January 2015. Insurance carriers had put into place more requirements before issuing prior authorization for surgical and diagnostic procedures.
“The rules get more stringent each year,” Williams says. “What amazes me is we can go to the insurance company’s website and do exactly what it says, only to be denied and have them say, ‘We haven’t updated our website yet.’”
Such denials sometimes can be successfully appealed, but this appeal process requires a large amount of rework. “We’ve challenged a lot of them, and some insurance companies will not pay retroactively,” Williams says. “They are now saying, ‘If you don’t get the precert on the front end, I’m sorry, that’s your loss.’”
Here are some changes the healthcare system has made to prevent clinically related denials:
• Staff obtain approval for implants or medications that might be used during surgery, if these require separate precertifications.
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,” Williams says. “We also instructed the scheduling team that if any implant is involved, to name it on the front end.”
• The surgical team quickly notifies case management of any changes or additional procedures.
In some cases, precertification was obtained for the patient’s surgery, but additional procedures were done during the surgery that weren’t anticipated. This change results in the entire claim being denied. Vicki Boyd, director of the centralized services division and former director of patient access services at Methodist University Hospital, 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.”
• The precertification team notifies the surgical team, patient access, and case management if precertifications are not in place by noon the day before surgery.
“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.”
• Staffing is increased as needed to obtain precertifications.
In some cases, staff members scramble to obtain required authorizations before the close of business, Boyd says. “We make sure to staff appropriately to meet those timeframes,” she says. “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.”
• Patient access asks physicians to have a “peer-to-peer” conversation with the payer’s physician if a high-dollar claim is denied for clinical reasons.
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-[to-]peer to push the procedure through,” says Williams. “In talking to another clinician, they may decide that the care is appropriate and approve it.”