Is there a problem with an authorization that will result in a denied claim? Good communication with providers and office staff about this issue has reduced avoidable authorization denials by 60% at LCMC Health in New Orleans, according to Stacy Calvaruso, CHAM, system assistant vice president of patient access services.
“Of those cases that were rescheduled, we have been approximately 80% successful in getting the cases cleared with appropriate payment,” Calvaruso reports. Patient access reschedules cases if the payer hasn’t responded to the authorization request or if the payer requires a peer-to-peer review.
“We contact the provider first to clarify whether the services are considered ‘urgent’ or ‘necessary,’ or not,” says Calvaruso. If the providers say the procedures can be postponed, patient access staff members ask them to inform the patients. “In some instances, we will contact the patients on the providers’ behalf if they are uncomfortable explaining the situation,” says Calvaruso.
If so, patient access employees tell the patient, “Mr./Mrs. Smith, this is Stacy, and I am with the pre-service center at LCMC. Your provider has asked that we assist them with getting you scheduled for XX procedure and to work with your payer to get an authorization from them to process and pay your claim. Unfortunately, we have been unable to obtain this authorization as of right now, and we will need to reschedule your visit. We will continue to work with your payer and your provider to get this approved and call you back to schedule you for your services.”
Alert provider’s offices
To avoid rescheduling, patient access clearly communicates payer requirements and the status of cases with providers’ offices.
“We also make sure that patients understand that this is a partnership and that they are equally as responsible in their payers’ authorization approval process as the clinicians are,” says Calvaruso.
At Birmingham, AL-based Baptist Health System, patient access leaders avoid problems that can cause a procedure to be postponed by starting early in the process. “We start when a patient is scheduled, by requesting the precertification information from the physician office,” says Wendy Lepp, corporate director of patient access.
After the patient has been scheduled, the pre-registration department contacts the patient’s insurance carrier to verify benefits and required authorizations. Patient access follows up with the physician’s office to obtain any necessary authorizations that are pending.
“We also have a team onsite at our facility who obtains pre-certs on behalf of the physician’s office and the hospital,” says Lepp. “We have developed a very good process.” The preregistration team communicates twice a day via email with patient access management, admitting staff, and financial counselors to let them know about any problems with patients scheduled for services.
“Maybe there is something that is pending. Maybe we were unable to obtain the benefits and can’t reach the patient,” says Lepp. “If so, we communicate that information in advance.”
Give office staff training
Only about 1% of procedures need to be rescheduled at Presence Saint Joseph Medical Center in Joliet, IL, and Presence St. Mary’s Hospital in Kankakee, IL. Amanda Hayes, regional director of patient access, credits this low percentage to educating providers’ offices on payer authorization requirements and the department’s financial clearance policy and process.
“We have tools and information about insurance authorization, such as online verification tools and payer contacts, that the physician offices may not,” she explains.
Members of the patient access staff ask staff members in the offices what time of day is best for them to come to the hospital campus to have training.
“We have found that a breakfast is great before provider offices open to patients. Or if the seminar is shorter, a lunch class also works,” says Hayes. By providing educational seminars to providers’ office staff, she says, “in the end, we guarantee an excellent patient experience.”