“No-auth” denials result in more than $250,000 written off per quarter for outpatient claims at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE, estimates Lisa Adkins, MSN, RN, CPNP, CRCR, director of patient authorization.
“Payers are requiring the medical rationale behind the request, including information on what other modalities have already been tried,” she says.
Payers aren’t satisfied with just the diagnosis and procedure codes. They want detailed documentation on why a procedure is necessary. Karen Watts, LPN, CHAA, patient access specialist at Conway (SC) Medical Center, says, “An upward climb in denials has occurred, as more and more insurance companies require clinical documentation to be exact with the billing codes. If not exact, revenue is lost.”
About one-third of all claims now need clinical documentation sent to avoid denials, adds Watts. “We see a total of about $2 or $3 million a month in claims that are denied,” she reports.
Payers are asking for the patient’s H&P, recent lab results, previous radiology summaries, and documentation showing that conservative treatment has been tried, “but we don’t get enough clinical information from the doctor’s office,” says Lynn Arrington, CHAM, director of insurance verification at Texas Health Resources in Arlington.
Patient access employees can sometimes bypass providers’ offices. “Since there is better technology today, we can access past medical records and obtain needed information ourselves,” Arrington explains. Where to find clinical information in the patient’s medical record is a key focus of employee training. “We have 16 facilities and thousands of doctors that we get clinical [information] from, and not all systems look the same,” says Arrington. “Getting that together before you even call for the authorization is the key.”
Conway’s patient access staff called each provider’s office individually to explain why clinical information is needed for claims. “We now get medical documentation a lot more efficiently,” says Watts. “Sending it with the claim for review makes payment faster and smoother.” Watts estimates that $500,000 in denials are avoided each month by submitting clinical documentation in a timely manner.
To decrease denials, Nemours/duPont’s patient access leaders set a goal of getting more than 98% of authorizations 10 days before the requested procedure. “We have worked with our providers to utilize templates in the EMR to make sure the clinical information is noted in the impression and plan from each visit,” says Adkins.
Prevent denials
The Division of Revenue Cycle Support Services at Salt Lake City, UT-based Huntsman Cancer Hospital has been focusing on reducing “controllable write-offs,” says Junko I. Fowles, CHAA, supervisor of patient access and financial counseling. These write-offs stem from no authorization, lack of medical necessity, and non-covered services.
The department created a template for a medical necessity letter and a medication order for pre-authorization. “This reduces the time providers spend on insurance authorization,” says Fowles. If patient access doesn’t receive the final treatment plan until the last minute, members of the pre-auth team ask the payers to review medications patients are likely to receive on the date of service.
Here are two challenges the department sees involving clinical documentation and payer requirements:
- The history and physical report is not dictated in a timely manner, so patient access staff members have to contact the ordering physician so the chart can be updated.
- Labs aren’t drawn until the day of admission, so the treatment plan cannot be determined until the date of service.
“Depending on the lab results, the physician may change the inpatient chemotherapy regimen, so a different CPT code needs to be authorized,” explains Fowles.
The department is seeing these three trends in payer authorization requirements:
- Due to lack of clinical documentation, claims are sent for peer-to-peer review.
“This may delay treatments,” says Fowles. (See related stories on peer-to-peers and denials resulting from the wrong CPT codes being authorized, in this issue).
- More payers are not allowing retro authorizations for requests received after the fact.
“The only the option left is to file an appeal when the claim is denied,” says Fowles. The likelihood of getting it approved, however, is “very slim,” says Fowles. “Based on my experience, we have a better chance of getting a denial overturned due to medical necessity than we do for failure to obtain authorization.”
- It appears that no authorization is needed because CPT codes are not on the payer’s pre-authorization list, but non-covered service denials occur.
“Since claims are subject to review, some cases will be denied if the services are considered experimental or investigational for the specific diagnosis,” explains Fowles. Off-label medication usage or certain types of radiation therapy are sometimes denied for this reason.
“We spend so much time figuring this out,” says Fowles. To avoid claims denials, the department is implementing a standardized template for providers and pharmacists to flag a medication as off-label.
“Better communication among ordering physicians, admitting, pre-authorization, and the financial counseling team is needed to avoid denials due to not meeting medical necessity requirements,” underscores Fowles.
- Lisa Adkins, MSN, RN, CPNP, CRCR, Director, Patient Authorization, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Email: [email protected].
- Lynn Arrington, CHAM, Director, Insurance Verification, Texas Health Resources, Arlington. Email: [email protected].
- Junko I. Fowles, CHAA, Division of Revenue Cycle Support Services, Huntsman Cancer Hospital, Salt Lake City, UT. Phone: (801) 587-4036.
- Karen Watts, LPN, CHAA, Patient Access Specialist, Conway (SC) Medical Center. Phone: (843) 234-6673. Email: [email protected].
