Payers may deny claims if a different procedure or additional procedure is done after the initial authorization was obtained. Patient access leaders at United Regional use these strategies:
- obtaining authorization for a range of procedures or medications;
- asking payers to update the CPT codes on the authorization;
- contacting office managers if additional procedures often are done with particular physicians, so that those CPT codes are included on future authorizations.
When a physician orders a procedure to be performed in a surgical setting at Birmingham, AL-based UAB Hospital, staff start the process of obtaining required authorizations.
Once the physician begins the approved surgical procedure, however, there might be changes. “There are sometimes instances where the expected procedure to be performed has to be modified based on findings during the actual surgery,” says patient access director Lee Patillo, CHAM.
Even with an effective upfront process, there are situations in which a procedure that was not scheduled originally is added on after the patient arrives for service. Amanda Taylor, director of patient access at United Regional in Wichita Falls, TX, says, “Some examples where we see this occur most frequently include diagnostic studies, infusion medications, and surgical procedures.”
Although the patient’s surgical paperwork usually contains language that allows additional and/or related procedures to be performed, the insurance company still might try to deny payment for the additional procedure. Many insurance plans won’t allow retroactive authorizations.
“This is an area that we have placed a lot of focus on,” says Taylor. “We successfully obtain approximately 99.8% of all authorizations required.”
Some payers allow a range of authorizations, while others will authorize only a single CPT code. “It is important to investigate this before the service is performed,” says Taylor.
As soon as they’re notified that additional procedures will be performed, staff members begin working immediately to obtain required authorizations.
“Some insurance carriers allow us to contact them directly to update the CPT codes on the authorization,” says Taylor. “Others require the physician to make those changes.”
Staff members can obtain authorizations only for services they are aware of, Taylor emphasizes.
For surgical procedures, staff members look at trending information, Taylor says.
For example, staff members sometimes notice that a particular physician frequently performs more than one procedure, even if only one procedure was scheduled. “In those instances, it is best to look at specific details, such as the type of procedures and how frequently it occurs,” says Taylor.
Next, staff members work with the physician’s office to develop a plan. “We reach out to the office manager and gain a better understanding of why we are frequently seeing changes,” says Taylor. In some cases, the additional CPT codes can be included in future authorizations upfront. “It takes a multidisciplinary approach to effectively manage denials due to lack of authorization,” Taylor emphasizes.
At UAB Hospital, utilization managers work with payers to obtain authorizations for any additional procedures that are performed.
“Once the updated authorization is obtained, the utilization manager updates the authorization in the hospital billing system,” says Patillo. “This prevents a denial.”