With medical necessity denials, “prior authorization is ‘job-one,’” says John Holyoak, director of product management at RelayHealth Financial, which is based in Alpharetta, GA.
“It’s frustrating for everyone when the payer determines that the diagnosis provided does not support the need for the service,” Holyoak says. “Fortunately, there are options to reverse some of these denials.”
Documentation of the patient visit and current medical literature can bolster appeals. “Send copies of your appeal letters to patients, encouraging them to get involved, too,” Holyoak advises.
He says that taking these five steps can help patient access departments reduce the number of medical necessity denials:
1. Use technology to alert you of required prior authorizations.
“This eliminates labor-intensiveness of a manual system, such as phone calls or perusing a collage of … notes noting ‘what worked last week,’” Holyoak says. Familiarity with pre-certification, frequency, and diagnosis requirements for major payers can be the difference between success and failure, especially with Medicaid claims, he adds.
In some cases, authorization verification is given, but the claim later is denied because the payer says it was never obtained. “This is a very common occurrence,” says Holyoak. He advises putting technology in place that provides an audit trail by storing the authorization verification result and date, and a link to the payer website response.
2. Train patient access staff to routinely validate the ordering diagnosis and procedure code against the payer requirements.
If staff members realize that specific documentation or diagnostic testing is required, it could prevent a denied claim.
3. Make sure your claim editing is as strong as possible.
Most payers have rules that change constantly — as often as quarterly. “An edit will alert you to an unmet requirement prior to submitting the claim. This may eliminate waiting weeks only to have the claim denied,” Holyoak says.
4. Determine where medical necessity denials are originating.
Was a required prior authorization not completed? Is a particular physician not documenting care adequately? Is a diagnostic test routinely being missed?
“This helps you understand which people in the organization need to be involved and what processes need to be modified,” says Holyoak.
5. Use your data to start conversations that need to happen.
In some cases, departments are unknowingly contributing to denials.
“Clear data that shows a particular group or person’s contribution to medical necessity denials can help speed change by gaining buy-in,” Holyoak says.