Executive Summary
By obtaining authorizations on behalf of physicians’ offices, patient access departments are reducing claims denials and increasing satisfaction. In 2014, Baptist Health had only three denials attributable to authorizations that they obtained on behalf of physicians.
-
Complete pre-registration and financial clearance sooner.
-
Notify patients quickly if the authorization is denied.
-
Compare what initially was approved to what was performed.
Each month, patient access employees at Birmingham, AL-based Baptist Health System handle more than 1,500 requests from physician offices to obtain authorizations for scheduled services.
“The biggest challenge is completing the volume of requests received daily,” says Wendy Lepp, corporate director of patient access.
A team of four patient access employees obtain authorizations for all scheduled procedures at Baptist Health’s four hospitals, including radiology and surgery. “We offer a web-based product solution that allows physician offices to route requests electronically to our precertification department,” says Lepp.
Previously, precertification was handled by an outside vendor. “Recently, these services were brought back in-house,” says Lepp. Physician office staff members can request that the facility contact the patient to schedule the date of service or that the facility obtain authorization on behalf of their offices.
“For those physician offices who request us to obtain the precert on their behalf, the orders are routed to a work queue for our team to work,” says Lepp. “Multiple areas can access the information.”
Radiology reviews orders in advance to ensure the correct test has been ordered. Case management can review orders for the authorization, and/or any other information provided by the insurance carrier. “This helps to ensure the patient is placed in the correct status when they are admitted or that the correct test is being ordered,” says Lepp.
Physician offices can access Baptist Health’s web-based application via a link on the hospital’s website, which also has training documents for how to use the system.
“After the physician offices are trained, we load the link as a desktop icon on their computer and also as a favorite webpage on their computer,” says Lepp.
She often receives emails and verbal feedback from physician’s office staff members who are pleased with the process. “It allows for them to concentrate on other responsibilities within their offices,” Lepp explains. “They appreciate having hospital staff, familiar with the precertification requirements, interact directly with the insurance carriers on their behalf.”
The facility benefits because there is verified confirmation prior to the patient’s date of service that the services to be provided will be covered. This step prevents claim denials. “In 2014, our precertification team had a total of three denials attributable to authorizations that they obtained on behalf of the physician office,” reports Lepp.
A change in the works
Irvine, CA-based St. Joseph Health doesn’t obtain authorization for physicians’ offices, but this process is about to change.
“This is on the forecast for the next fiscal year,” says Judy Parker, MSL, regional director of patient access. “Although we have not begun the process, in speaking with physicians’ offices, this is one area that they would like to see us undertake.”
Requesting authorizations can be time-consuming. “Physicians’ offices, just like hospitals, are looking for efficient ways to streamline their processes,” says Parker.
Currently, members of the hospital’s centralized pre-registration/financial clearance team call insurance companies to confirm the authorization initiated by the physician’s office. “The team confirms that the authorization is for the correct dates of service, the correct CPT and ICD-10 codes, and that it is for the hospital’s tax ID,” says Parker.
Soon, the team also will obtain authorizations for staff members at physician offices, as long as they submit the necessary documentation and a complete order. “The challenge for the patient access team is that the documentation received from the physician’s office isn’t always thorough enough to provide the payers with the needed information,” says Parker.
Whenever this situation happens, patient access has to call the physician’s office to obtain the additional information requested by the payer or request that the physician make the follow-up call to the payer. “Often, we have found that the pre-registration team is calling the payer to verify the authorization ahead of the physician’s office actually initiating the request for authorization,” says Parker. By initiating the authorization themselves, patient access staff members will be able to complete the pre-registration process and financial clearance sooner, before the patient’s date of service.
“If the team is able to notify the patient further in advance if the authorization has been denied, it allows patients to contact the physician to make informed choices on the direction of their care,” notes Parker.
One-stop shop
Patient access leaders at Bethel-based Western Connecticut Health Network created a centralized financial clearance center to financially clear all patients on behalf of providers.
“The time and effort proved to be of great benefit, as the denial rate dropped considerably,” reports patient access manager Rosa Rivera, CHAM.
The process mimicked the already-established hospital financial clearance process. “It was very efficient,” says Rivera. “But it still did not promote customer service satisfaction to the level that it should.” Patients still were receiving at least two phone calls: one from the medical group team, and one from the hospital team. “Last year, we ventured into new territory by combining both financial clearance centers into one centralized unit,” Rivera says.
Patient access staff now perform the financial clearance for the physician and the hospital simultaneously. Patients receive just one call to discuss benefits, out-of-pocket costs, pre-registration, and collections.
The successful process “did not happen overnight,” however, says Rivera. “It took the dedication of two directors, one manager, and five supervisors to guide the team,” she says. “Today, we see the benefits of this ‘one-stop shop.’”
Post-procedure problems
In some cases, Baptist Health System’s precertification team obtains all of the required authorizations, verifies insurance, and collects the patient’s out-of-pocket responsibility, so everything appears to be going smoothly.
“However, additional authorizations are needed post-procedure,” says Lepp. “Sometimes, the auth that we obtain is not the appropriate one.”
During surgery, a different or additional procedure is sometimes performed that wasn’t authorized beforehand. When a patient undergoes a screening colonoscopy, the procedure sometimes changes to a diagnostic colonoscopy after the physician begins performing the procedure.
Janice Ridling, MPA, CHFP, vice president of revenue management, says, “What we are finding is that payers are not very flexible. They are telling us, ‘We authorized X, and the physician did Y, so we can’t pay you.’ That has really gotten to be a big challenge in recent months.”
If the discrepancy is discovered after the claim has been billed, appealing the denials usually is unsuccessful. “If we do see a particular payer is absolutely refusing to work with us on those types of scenarios, we’ve even gone so far as to get our CFO involved,” notes Ridling.
The department is trying a new process so patient access can compare what initially was approved to what actually was performed. Success hinges on excellent communication with the physician’s office.
“Timing is key,” says Ridling. “If the patient is still here, I’m hoping that the payers will work with us a little bit more.”
-
Wendy Lepp, Corporate Director, Patient Access, Baptist Health System, Birmingham, AL. Email: [email protected].
-
Judy Parker, MSL, Regional Director, Patient Access, Southern California, St. Joseph Health, Irvine. Email: [email protected].
-
Janice Ridling, MPA, CHFP, Vice President, Revenue Management, Baptist Health System, Birmingham, AL. Email: [email protected].
-
Rosa Rivera, CHAM, Patient Access Manager, Western Connecticut Health Network, Bethel. Email: [email protected].
