Are all the required authorizations in place for a procedure? Meeting this requirement doesn’t mean much if a different procedure is done.
“It is difficult to predict what the physician will do once the patient is in the room,” explains Ketan Patel, a senior manager in the healthcare provider segment of strategy and operations for New York City-based Deloitte Consulting. “This requires significant clinical documentation post-service to prove necessity and overturn denials.”
Some claims denials stem from incorrect CPT codes given by providers. At Arlington-based Texas Health Resources, this problem was cropping up with radiology services, says Lynn Arrington, CHAM, director of insurance verification. “We give that information back to the hospital, who then communicates it to the radiology department,” she says. “Since they know the cause of the denial, everybody is on the same page about what we need to do.”
Insurance verifiers then call the payer to see if the CPT code can be changed. “Our denials on [radiology] have gone down, but for heart procedures, denials have gone up,” says Arrington. “The doctor’s office is scheduling one CPT code, but it really should have been something else.”
The patient access department at Wilmington, DE-based Nemours/Alfred I. duPont Hospital for Children is focused on decreasing “no-auth” denials due to a miscommunication of the proposed procedure or a change in codes performed from the codes authorized. “We continue to work on a process for catching code changes post-procedure,” says Lisa Adkins, MSN, RN, CPNP, CRCR, director of patient authorization.
Alerting payers of the discrepancy isn’t any guarantee the claim will be paid. “Many payers have very strict timelines for resubmission of ‘changed/additional’ codes that were not authorized prior to the procedure,” Adkins explains.
Here are two common examples of discrepancies that cause claims denials:
- Precertification is obtained for a CT scan with contrast, but one without contrast is performed, or vice versa.
In these cases, says Karen Watts, LPN, CHAA, patient access specialist at Conway (SC) Medical Center, “most insurance will not pay.” To avoid this, patient access makes sure the hard copy precertification from the insurance company matches the physician’s orders.
- A procedure was done in the OR in addition to what originally was authorized.
“In some cases, sending OR notes to explain why another procedure had to be done can prevent the denial,” says Watts.
Patient access now obtain the physician’s orders via electronic fax at the time of scheduling. “We also ask that if authorization had to be obtained prior to scheduling the procedure, to fax us a copy of that with the orders,” says Watts. Patient access staff compare the CPT codes on the authorization documented with the insurance company with the physician’s order. “If authorization has to be obtained, we ask that it be sent as soon as possible so we have time to compare the two hard copies,” says Watts. “If we do not have a hard copy of the authorization, we recover it online or through a phone call to the precertification company.”
If patient access staff members spot a discrepancy, they take immediate action. “We call the physician’s office to clarify what the doctor wanted versus what CPT code was pre-certed,” says Watts. The physician’s office then can modify the authorization, or the physician can modify the order.
“This almost always avoids a denial,” says Watts. “Of course, there are times that no matter how much information is sent to the payer, they still do not pay.”
