Patient access departments continue to see medical necessity-related claims denials due to increasing and complex payer requirements. To prevent these:

  • ensure all tests, procedures, and hospital stays have been verified for medical necessity;
  • check patient orders against payer policies;
  • educate employees on how to interpret medical necessity checks.

Patient access departments continue to see claim denials, often unfairly, because they don’t pass meet payers’ medical necessity criteria.

“Payers, both federal and non-federal, are increasing the requirements for medical necessity. The patient access role is that of a gatekeeper,” says Peggy Stavitz, chief patient accounting officer at Eastern Maine Healthcare System in Brewer. The biggest challenge is to get all services — tests, procedures, and hospital stays — verified as medically necessary beforehand.

“It is often difficult to verify prior to services,” Stavitz notes. “Often, slight variations are performed based on specific protocols.” It’s not just that medical necessity requirements are becoming more numerous, although that’s certainly true. They’re constantly changing, too, and are different for every payer. Frequently, additional codes or modifiers are needed to satisfy the requirements of a particular payer — impossible for any registrar, no matter how diligent, to track. Thus, says Stavitz, “the best way for patient access to arm against denials is to use technology that checks the patient order against the payer policies.”

Sometimes, education of patient access employees on medical necessity is lacking. Stavitz underscores that staff need a grasp on the following three things:

  1. The definition of medical necessity;
  2. How to use technology to determine if a service meets the payers’ requirements;
  3. How to interpret the results of the medical necessity check. If anything doesn’t check out, says Stavitz, “appropriate next steps need to be taken to reduce the number of avoidable denials.”

Denials on Back End

In some cases, insurance companies approve the authorization, or tell patients that no authorization is needed. Yet, a few weeks down the road, the hospital isn’t paid.

“They are denying things on the back end and deeming them experimental,” says Stacy Hutchison-Neale, CRCR, CHAA, supervisor of the pre-authorization department at Nemours Alfred I. DuPont Hospital for Children in Wilmington, DE. Two common examples: outpatient infusions and capsule endoscopies. When this happens, a time-consuming phone call is on the agenda for patient access, wreaking havoc with productivity. Staff take up to 30 minutes to contact the payer and sort it all out. Satisfaction takes a hit, since the patient has already received the services and gets an unexpected bill stating it was deemed experimental. “In reality, some of the patients have been on the medication for months or years without a problem getting the claim paid,” Hutchison-Neale says.

Suddenly, it doesn’t meet the criteria outlined for the medication in the payer’s clinical policy. Sometimes, the payer criteria changed; other times, the payer is simply interpreting existing criteria differently. Recently, a payer began basing dosage criteria on the patient’s age, when it’s actually calculated by the patient’s weight. This caused some claims to be denied.

“There is a lot of lot of rework and backtracking,” Hutchison-Neale laments. These steps occur:

  1. The business office notifies patient access that the claim has been denied.
  2. Patient access tries to research the denials. If unable to resolve it, they forward it to the pre-authorization team.
  3. The pre-authorization team pulls the policy again and reviews the possible reasons for denial. Next, the team calls the insurance company’s claims department. “These are lengthy calls because they have to research the case from the initial request we submitted,” Hutchison-Neale says.
  4. If the payer requests an updated dosage, the team requests a new authorization and starts all over.

The best-case scenario is that the payer representative acknowledges the mistake and resubmits the claim for payment.

“There are cases where it just takes talking through the claim and it gets overturned. The sad part is that it takes rework to get this resolved,” Hutchison-Neale adds.

15 to 30 Days to Resolve

Payers don’t make it easy to find their clinical policies.

“They do not make them clear in non-technical language so that everyone understands them, including the families,” Hutchison-Neale says.

To stem the tide of denials, the pre-authorization department created a new approach. First, they pull the health plan’s medical policies to review them. Utilization nurses get involved, reviewing the patient’s clinical chart against the payer’s clinical policy. “They can advise us if they feel that it is medically necessary based on the criteria,” Hutchison-Neale notes. Next, the pre-authorization team requests a pre-determination (a review of the medical policy) by the payer. Not all insurance companies offer this option. “But for those that do, we submit the clinical and the requested CPT codes,” Hutchison-Neale says.

The payer reviews the submission and provides a determination based on the clinical policies as to whether the procedure is covered. “The entire process can take anywhere from 15-30 days to complete,” Hutchison-Neale explains. “However, the good part is that it does decrease the denials.”

Patient access has successfully appealed some of the denials. “But sometimes the insurance will not budge,” she adds.


  • Stacy Hutchison-Neale, CRCR, CHAA, Supervisor, Hospital Pre-Authorization Department, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE. Phone: (302) 651-5184. Fax: (302) 651-4224. Email: Stacy.HutchisonNeale@nemours.org.
  • Peggy Stavitz, Chief Patient Accounting Officer, Eastern Maine Healthcare System, Brewer. Phone: (207) 973-4642. Email: mstavitz@emhs.org.