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Payers ask for additional clinical documentation to demonstrate medical necessity before paying claims. Registrars at the University of Chicago Medicine take these steps:
Some patient access departments see a surge in claims denials due to “medical necessity,” with payers claiming the service wasn’t medically necessary. “We are seeing the large plans beginning to be more stringent with their guidelines, causing an increase in the medical necessity denials,” reports Heather Nieto, director of patient access at the University of Chicago Medicine.
Most denied claims are for infusions and unplanned surgical admissions. “In our authorization process, we attempt to obtain predeterminations in addition to precertifications,” Nieto explains. This is required specifically for all off-label use infusions and procedures. “This is a bit more cumbersome, because predeterminations cannot be completed online,” Nieto notes. “They must be called in.”
This poses a staffing issue, since the prior authorization team handles authorizations online, not time-consuming phone calls. A motivating factor: Payers often ask for a peer-to-peer review with the physician, if the necessary clinical data isn’t submitted at the onset. “We do everything we can to avoid this,” Nieto says.
As for clinical documentation, registrars can obtain it directly from the EMR, which, at a minimum, includes the last history and physical, the last visit clinic notes, and any testing that has taken place prior to the requested service. Registrars print whatever is required, then fax, scan, or email it directly to payers.
“If there are not sufficient clinicals in the EMR, we contact the specific clinic to get the necessary data and submit it,” Nieto explains. “Our goal is always to have a midlevel provider or nurse to contact.”