Patient access diligently obtains a required authorization from the payer and the service is scheduled. Weeks later, the claim is denied. However, it is not for “no auth,” but because the payer says it was not medically necessary.

“Some payers actually issue an authorization, but once claims are received, they are denying for medical necessity,” says Maria Lopes-Tyburczy, CHFP, director of patient access at Hackensack Meridian Health Palisades Medical Center in North Bergen, NJ. Mostly, this happens with inpatient admissions. Payers either downgrade the patient status to observation, or deny the entire claim. The claims always are appealed. “But we have very little success overturning the payer’s initial decision,” Lopes-Tyburczy laments.

There are two ways patient access is tackling this costly problem:

  • Staff identify when a payer consistently denies claims for medical necessity, even when the authorization was in place. Patient access contacts the payer’s representative assigned to the hospital. “Conference calls are scheduled to review claims and come to a resolution,” Lopes-Tyburczy explains.
  • Staff are careful to meet all payer requirements. For outpatient scheduled ancillary services and same-day surgeries, patient access verifies coverage and benefits beforehand. This ensures that the procedure is covered under the patient’s policy, avoiding a “noncovered service” denial.

“Patient access works very closely with the referring physician’s office,” Lopes-Tyburczy says. All clinical information required by the payer is sent in a timely manner. If preauthorization requirements are not met the day before a scheduled procedure, both the patient and the physician are notified. The procedure is canceled and rescheduled. Constant communication with payers and physicians is needed to avoid problems.

“Patient access is very diligent in ensuring that all information is obtained prior to date of service,” Lopes-Tyburczy reports.

Obtaining authorizations for scheduled services is difficult enough. If time frames are shorter, it is even more challenging. “The struggle comes when physicians send patients for stat procedures,” Lopes-Tyburczy notes.

When this happens, patient access employees:

  • obtain the preauthorization requirements from the payer after verifying coverage and benefits;
  • contact the referring physician’s office, tell that office to follow up with the payer, and obtain a case number.

Sometimes, the referring physician calls the payer and conducts a peer-to-peer review with the payer’s physician. Hopefully, this results in authorization. “If the payer states that the case is still in review, the stat procedure is done,” Lopes-Tyburczy says. “Patient access follows up the next day.”

Payers are constantly changing their medical necessity criteria. This further complicates matters. “Patient access staff training is ongoing,” Lopes-Tyburczy says.

For walk-in patients, the medical necessity check occurs at time of registration. If medical necessity criteria are not met, the physician’s office is contacted. “In some cases, patient access [staff] obtain additional diagnosis codes that are documented in the patient’s chart,” Lopes-Tyburczy says.

If no additional information is obtained, or if patient access cannot reach the physician’s office, an Advance Beneficiary Notice (ABN) is issued to the patient.

“The patient can opt to have the procedure done and be financially responsible if Medicare denies the procedure,” Lopes-Tyburczy says. The patient also can opt not to decline the procedure. Either way, patient access notifies the physician and ancillary department of the decision.

“A copy of the ABN is given to the patient. We scan a copy into the EMR for future reference,” Lopes-Tyburczy adds.

This comes in handy if the patient ends up undergoing the procedure later. The registration system automatically alerts the patient accounting system that the patient accepted financial responsibility if Medicare denies the claim.

For all Medicare beneficiaries, a medical necessity check is performed using the information the physician’s office provided. For scheduled ancillary services, a different process is used. At the point of scheduling, ancillary departments request that the physician send an order with the required information. This allows patient access to conduct the medical necessity check before the date of service.

“This gives us enough time to reach out to physicians’ offices for additional diagnosis codes if needed,” Lopes-Tyburczy says.