Payer requirements are all somewhat different, and they’re constantly changing. “We use a variety of methods to stay current,” says Betty Bopst, CHAM, patient access director at Mercy Medical Center in Baltimore.
Payer reps are one of the most important sources of information. “They visit onsite, send email notifications, and offer webinars,” Bopst notes. Mercy’s insurance verification team constantly monitors payer websites, too. Recent changes include payers allowing total knee replacements in outpatient settings, payers requiring notification of observations at the 24-hour mark, and drugs not requiring prior authorization (but are denied billing time).
Viviana Beland, financial clearance unit manager at Moffitt Cancer Center in Tampa, FL, keeps employees current by reviewing monthly bulletins from the major insurance companies, meeting periodically with insurance representatives who give updates on authorization requirements, and looking for changes in authorization requirements on payer websites (particularly at the beginning of the year and July, when most changes happen), and verifying whether authorization is needed for every single encounter, even recurrent ones such as infusion treatments.
“With this process, we are able to determine if a requirement changed from one month to the next,” Beland reports. One major payer didn’t require an authorization for the chemotherapy drug folinic acid. However, this changed suddenly mid-treatment. Staff discovered the change when verifying authorizations for the following month.
“Otherwise, we would have assumed no authorization was required. We would have gotten a denial on the back end,” Beland explains.
Many patient access departments only check authorization requirements at the beginning of treatment. That’s no longer enough, according to Beland. “We double check authorization requirements for all drugs, every month. It is part of our quality process.”
Moffitt’s denials authorization team was moved to the front end as part of the financial clearance unit. “This allows the hospital to identify missing authorizations that resulted in a claim getting denied by the payer,” Beland says. Any change in authorization requirement is communicated immediately to the financial clearance specialist. The team that processes authorizations submits a retroactive request for any missing.
With this new process in place, the department’s denial rate decreased from 15% to 8%. “Thanks to the quick communication given to the front end, we only miss a few authorization requests,” Beland reports.