EXECUTIVE SUMMARY

Payers are requiring up to 10 days to review authorization requests, putting patient access in the position of possibly rescheduling patients if accounts can’t be financially cleared. Patient access can:

  • explain the process to clinicians to reduce frustration;
  • ask higher-ups to determine if the patient can be scheduled without the authorization in place;
  • ask payers to expedite the process, if possible.

Payers want up to 14 days to review a simple authorization request. Meanwhile, physicians want to schedule patients ASAP. Patient access is caught in the middle.

“Of course we want all our patients to be able to come in as planned. But sometimes we can’t reach a point of financial clearance,” says Joseph Ianelli, director of patient financial services at Massachusetts General Hospital in Boston.

If the payer won’t give the authorization in the timeframe the physician wants, Ianelli says, “there are a number of different things we have to think about.”

One is the high frustration level of clinicians, who don’t understand why their patient can’t be scheduled as planned.

“We explain what the process is, and why we can’t move forward,” Ianelli adds.

Kim Rice, MHA, patient access director at Shasta Regional Medical Center in Redding, CA, sees payers scrutinizing more details on authorization requests. “We must keep up to date on the requirements and expectations,” she says.

Securing financial approval sometimes means getting on the phone, which is time-consuming. “Certain payers, such as Blue Cross, can take over an hour to just get through to speak to the representative,” Rice notes.

Urgent Need Conveyed

Patient access sometimes contacts payers and conveys the urgent need for the approval, with mixed results.

“In my experience, the payers want to help out. Most payers are willing to do their best to process the auth sooner,” Rice says.

Sometimes, payers bring an honest mistake to the attention of patient access, such as incorrect or missing CPT codes.

Ashley Walker, patient access authorization supervisor at four Health First hospitals in northeast Florida, says most commercial payers give a response within 24 hours if the authorization is not approved automatically.

“Some payers require that a physician signature be submitted if patient access is requesting an expedited review,” Walker says.

Once the request is received, it’s processed within three business days.

The hospital’s central scheduling team verifies the patient’s insurance when booking the appointment, taking timeframes into account.

“They push the appointment out according to the health plan’s authorization processing time frames,” Walker explains.

For instance, if a patient presents with Aetna insurance, the appointment is scheduled five business days out, but if the patient presents with Medicaid, it’s scheduled for 14 days out.

“This gives our team enough time to process the authorization,” Walker says. If the team is unable to obtain the authorization in time, they inform centralized scheduling to either cancel or reschedule the appointment. Patients are informed this is a possibility. (See related stories in this issue on payer contracts and the rescheduling process.)

“Our auth team also picks up the phone and calls the specific payer to make sure that they’re aware the appointment is an ASAP or STAT,” Walker says. “This hopefully speeds up the review process.”

SOURCES

  • Joseph Ianelli, MGH, Director, Patient Financial Services, Massachusetts General Hospital, Boston. Email: jianelli@partners.org.
  • Kim Rice, MHA, Director, Patient Access, Shasta Regional Medical Center, Redding, CA. Phone: (530) 229-2944. Fax: (530) 244-5185. Email: krice@primehealthcare.com.
  • Ashley Walker, Patient Access Authorization Supervisor, Health First, Rockledge, FL. Phone: (321) 434-5459. Fax: (321) 434-5420. Email: Ashley.Walker@health-first.org.

Reschedule Elective Procedures as Last Resort

If no authorization is in place for a truly elective service, with no adverse consequences for the patient, it’s rescheduled, but patient access avoids using that word at Massachusetts General Hospital. “We use the word ‘postponing.’ That gives the patient hope that we can get to a place of ‘yes,’” Joseph Ianelli says.

Sometimes, a clinician simply wants to put a patient in an opening in the schedule. If there is a medical reason why the service needs to be performed earlier, an escalation process occurs. In these cases, Ianelli says, “we get the front-line people out of the decision-making.” The hospital’s chief medical officer makes the final decision as to whether the hospital is going to take the financial risk of scheduling the patient without the authorization in place.

To keep such situations to an absolute minimum, patient access starts the process two weeks in advance. “If we work too far out, the patient’s insurance could change,” Ianelli explains. Any sooner, though, and payer time frames aren’t met. That means the service might need to be rescheduled on short notice, something patient access tries to avoid at all costs.

“Nobody should have to call a patient one day before to reschedule, when it’s been booked for a month,” Ianelli says. At Shasta Regional Medical Center, the five business days required by most payers is a “huge challenge for the financial counselors who vet the account for financial clearance,” Kim Rice says.

If the patient access team doesn’t receive an authorization by the day before the patient’s scheduled service, they ask the office to reschedule. “It is rare that we have to do this. But my team is looking out for the facility’s and patient’s best interest. We do not want a denial,” Rice says.

Monique Williams, manager of patient financial services at Montefiore Health System, says payers are requiring between three and 14 days to approve authorizations. “Some health plans recently changed their policy to only provide authorization the day before a patient is set to arrive,” she adds. For all cases in which the procedure is not authorized 72 hours prior to arrival, patient access notifies the department that the patient is missing an authorization. They specify what time frame the health plan allows to obtain it.

“If there is no time to obtain authorization by scheduled surgery date, the physician is contacted, and a new date is determined,” Williams says.