At first glance, offering to obtain authorizations on behalf of physicians’ offices sounds like a lot more work. However, a move like this can benefit the department in more ways than one.
Stillwater (OK) Medical Center implemented a new centralized prior authorization process in 2017. This process is used for 23 clinics that are either owned or managed by the hospital.
“We started with less than 10 prior authorizations the first month. In October, we did over 300,” says Renee Swank, CHAM, patient access services director.
To start, clinics email the patient’s information to a group of prior authorization specialists, who are part of the central registration department. These employees use spreadsheets to track the status of each prior authorization. Once authorization is received, the central scheduling department is notified to call and schedule the patient. The schedulers email or note in the clinic EMR when the patient is scheduled.
“We have had to tailor the process for some clinics that use different EMRs,” Swank says. “But it has been a huge satisfier for our physicians.” There are fewer claims denials, and registrars are much less stressed. “They are in control of the authorization process,” Swank adds.
Previously, registrars were left wondering if the clinic had started the process at all. They were left guessing as to whether the authorization would be received prior to service. Now, there is a strong rapport between clinic staff and prior authorization specialists. “We get requests from new clinics to be added to the process daily,” Swank reports.
As of early 2019, Petersburg, WV-based Grant Memorial Hospital’s patient access staff is obtaining authorizations for physicians. “We are starting with one clinic, not hospital-owned, as a trial,” Patient Access Manager Anna M. Ours says. Shortly afterward, the service will be opened to all physician offices.
“The position will be covered by patient access staff,” Ours explains. Initially, the department posted the position for a new hire. “But since we are rolling out the program slowly, we decided to use current patient access staff to fill the role,” Ours adds. The position was given to the department’s most senior scheduler. First, the scheduler contacted insurance companies and physician office staff who currently obtain authorizations.
“We did this to get ahead of the game so that when we had our first request, we would know the paperwork to ask for in advance,” Ours says, noting this will eliminate some back-and-forth between patient access and the physicians. “The point of the new department is to make it easier for physicians. If they spent more time assisting us on the phone, then the new process wouldn’t be worth it.”
Once the request for authorizations increases, the position will be expanded. The full-time schedulers and one part-time scheduler will schedule, preregister, and obtain authorizations. “In the future, we will also work on OBS accounts to get their radiology procedures authorized,” Ours says.
A flood of missing and incorrect authorizations motivated Rockledge, FL-based Health First to create an authorization management team in 2011. Frequently, authorizations provided by physicians’ offices were for another procedure, the wrong service date, or the wrong facility. “We now obtain authorizations on behalf of all of our patients when needed,” says Michelle Fox, DBA, MHA, CHAM, director of revenue operations and patient access.
Change did not happen easily. Patient access staff had to learn each payer’s preauthorization requirements. “We needed enough lead time from when the patient was scheduled to the actual service date,” Fox recalls. Another challenge was gathering all the required information from the physician’s office.
One central phone line and one fax line is available to patients and physicians’ offices to request authorizations.
“The call center is available on an equal basis to all patients and physicians, without regard to any physician’s overall volume or value of potential referrals,” Fox notes.
The department has had a robust preregistration process in place for years.
“‘No authorization’ denials were not a big problem for us,” Fox says. However, when the authorization management team first started, there was an immediate uptick in workflow efficiency.
“Our team did not have to chase down authorizations through numerous phone calls and emails to the physician offices,” Fox adds.
Since 2006, Birmingham, AL-based Brookwood Baptist Health used an outside service to obtain authorizations on behalf of physicians and clinics for services performed in the facility. That changed several years ago.
“We initiated a process that allowed us to bring these services in-house,” says Wendy Lepp, corporate director of patient access.
Patient access had a good relationship with the vendor. “But we needed to be good stewards of our resources,” Lepp says. By bringing the services in house, physicians’ offices get the same level of attention, but at a lower cost.
“We reviewed several products that would enable this in-house capability,” Lepp says. A product was selected that allowed the physicians’ offices to provide all the necessary information to obtain authorizations for procedures and tests.
Job descriptions, staffing, space, and software needs all had to be considered when setting up the new precertification department.
“We decided to start with a team of four employees and one supervisor,” Lepp recalls. The supervisor also is a licensed practical nurse, ensuring good communication with clinicians.
“When we rolled the product out to physicians’ offices, we hosted a series of lunch-and-learns,” Lepp says. Patient access gave some one-on-one training to the physicians’ offices that elected to use the system.
When the new process started in 2014, about 25,000 requests for authorizations were completed. Demand has surged each year. When the requests hit 35,000, another team member was added. “In 2017, our team completed 42,617 precertification requests with only four denials,” Lepp reports.
Offering the precertification service by staff with a very thorough understanding of insurance requirements is a win-win.
“It allows physicians’ offices to focus on patient care,” Lepp says. “The facility receives payment for services performed with fewer denials.”