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Anyone who finds out he or she needs a diagnostic test urgently already has a lot on their mind. The last thing they are probably thinking about is how long it will take for their insurance plan to decide if it is even going to cover the test.
“For nonurgent services such as diagnostic scans, the auth review could take up to 15 days,” says Junko I. Fowles, CHAM, supervisor of patient access and financial counseling at the Huntsman Cancer Institute in Salt Lake City, noting that the preauthorization team makes same-day and next-day add-ons a top priority. “If it’s an urgent add-on and gets denied due to no auth, we’ll appeal the denial.” If the appeal is unsuccessful, the patient typically is not billed.
Payers are not all the same when it comes to time frames. Major payers (who use third-party utilization management administrators) usually take two or three business days, according to Fowles. In contrast, some Medicaid and Medicare Advantage HMOs take double or triple that time.
Staff has found it helps to mark some services “urgent.” These are usually radiology add-ons as well as surgery and inpatient admission. “The insurance utilization management team expedites the review of these cases,” Fowles explains.
Cases of patients with chronic illness (such as heart disease, cancer, or transplants) are not usually held up. That is because these cases are reviewed by case managers, who already are familiar with the patient’s situation. “As soon as they review the most recent clinicals, preauth can be approved within 24 hours of the submission,” Fowles says.
Sometimes, no authorization is required — at least according to the payer rep. The problem is that another entity is really the one making the decision. It turns out that a separate company handles authorization requests for the payer. “Later, the claim is denied because the third-party authorization company was not contacted,” says Karan Levering, CHFP, assistant vice president of preaccess services at Mariottsville, MD-based Bon Secours Mercy Health.
Average turnaround time for authorizations is somewhere around a week, but some payers take twice that long — not a day sooner than their contracts allow for. “Several payers, including medical mutual and our managed Medicaid plans, typically utilize the entire 14-day time frame,” Levering reports.
To try to get an answer on what is taking so long, revenue cycle employees sometimes spend 45 minutes on a single call. They are forced to work their way through an automated phone tree before they can talk to a person. “The phone system at many payers is cumbersome and complicated,” Levering says.
Patient access leaders offer these techniques to help speed and simplify the authorization process:
• Examine problematic payer contracts. “It is important to review and understand contract terms. Often, these may allow for long response times,” Levering says. If contracts allow payers to take up to four weeks, they probably will. Patient access employees are not directly involved in payer contracts, but they still can do something about the issue. “Leaders can enlist the help of the hospital’s managed care department if there are issues with authorizations,” Levering suggests.
To add to the misery, payers sometimes take even longer than their contract allows. “Though not the norm, this can create additional challenges,” Levering adds.
• Use automated technology to verify authorization status. “This is one of the most beneficial improvements we have seen,” Levering notes. Tools can tell registrars if an authorization is needed. It also indicates the status of authorizations daily, eliminating cumbersome manual checks.
“This has greatly increased productivity for our preaccess teams,” Levering reports. If a valid authorization is on file with the payer, it is removed from the worklist automatically. If no authorization is in place, the tool prompts the associate to follow up.
Some payers post authorization requirements online; however, this often does not occur at the CPT code level, according to Levering. Not all payers accept electronic requests for authorizations. Those that do vary greatly on how they want it submitted. “This takes additional resources and time to complete,” Levering says.
• Streamline the peer-to-peer review process. Payers are requiring many more peer-to-peer reviews, with the patient’s physician and the insurance company’s physician reviewer discussing the case on a call. “It is challenging for physicians to find time during their day to stop and complete these,” Levering observes.
• Assign patient access employees to obtain authorizations. Like most health systems, Paterson, NJ-based St. Joseph’s Health is seeing a huge increase in authorization requirements.
“The HMOs have increased the amount of CPTs that will require authorizations by 25%. This seems to change constantly — without any real reason for the change,” says Patient Access Manager Samirah A. Merritt, DBA, MBA. Payer time frames have grown longer (up to two weeks).
A typical scenario: A patient receives a prescription for a diagnostic test. The registrar contacts the physician’s office that sent the patient for the test to let them know the patient came for testing. At that point, the office should request authorization from the insurance company. They do not always do so. The next day, the registrar checks the status. Sometimes, nothing at all has happened to secure authorization. “It can take up to a week to return the information. In some cases, the 48-hour window has closed,” Merritt says.
The provider has that much time to request an authorization after the service is ordered. After the time is up, the payer will not give the authorization. Ultimately, the claim is denied only due to the timing of the request.
If the cutoff is approaching, registrars do what they can to speed things up. If all else fails, Merritt calls the office manager directly to explain the urgency of things. “To help combat this issue, we have assigned two people to the high-dollar modalities,” says Merritt, who notes these employees normally handle outpatient registration. “On their downtime, they use the previsit workflow to ensure we obtain the auth prior to the patient’s arrival.”
The department has found some success in this approach, but it comes at a cost to productivity. Staff are spending much more time reaching out to doctors’ offices. “In some cases, we are following up all the way until the patient goes up for their procedure,” Merritt reports.