Registrars are canceling procedures on short notice much more often these days, not because anyone needs to reschedule but because insurance companies are contacting patients to tell them the hospital setting will cost more. “We frequently see patients cancel their hospital-based radiology study to pursue cheaper studies at an outpatient free-standing facility,” reports Jessica Budri, RN, MSN, APRN, senior manager of patient access at Connecticut Children’s Medical Center in Hartford.
Usually, the free-standing centers are not pediatric-specialized. Thus, families are not choosing them for any reason other than cost. “We are seeing this in our outpatient hospital surgery ambulatory center, our radiology department, and our infusion center,” Budri reports.
In the infusion center, parents are resistant to switching to an outpatient center. This is due to strong bonds with their child’s provider, who may have followed them for many years throughout their childhood. “They prefer the pediatric setting, with nurses who are specially trained in this type of care,” Budri says.
Still, parents feel they are left with little choice due to payer policies. “The insurance companies are pushing more and more patients, of younger and younger ages, to outpatient infusion centers that are not hospital-based,” Budri says.
Payers are calling patients right before their appointment to tell them that the infusion will be denied if it is performed at the hospital-based facility. “This is the worst-case scenario,” Budri laments.
Staff have gone through the authorization process already; everything is in place to proceed with the service. “It’s causing undue angst to the patient and disrupting their plan of care,” Budri observes.
The last-minute cancellations are interrupting time-sensitive care and wreaking havoc with scheduling. “It has greatly impacted the complexity of the authorization process,” Budri says. “This leads to decreased productivity.” Registrars, pulled away from the work of obtaining authorizations for other patients, are left with a cancelled procedure and a confused patient. They do what they can to help. “We push all families to contact their employer and insurance plan directly to advocate on behalf of their children,” Budri says.
Patient access does its best to appeal the denial. “We often proceed with the care while the appeal is processing,” Budri explains.
Previously, physicians engaged in a face-to-face interaction with the patient once every six to eight weeks when the patient came in for his or her infusion. Now, physicians have lost that opportunity. “They only see [patients] if complications arise, putting them at risk for the small complications, which could’ve been caught earlier during that routine infusion check-in,” Budri says.
Following every step of the appeal process to the letter has overturned some denials. At first, the success rate was about 70%. “But we are seeing that decline. We are seeing less success with older patients. Now, less than 25% of patients over 17 get approvals through the appeals process,” Budri says.
Peer-to-peer sessions, when the patient’s treating physician discusses the case directly with the insurance company’s physician, sometimes result in approvals. “We have had to educate physicians on the importance of ‘fighting the fight,’ if you will,” Budri explains.
Physicians are in full support of the patient continuing to receive treatments at the hospital. They simply do not have time to make lengthy phone calls to the insurance companies. “This becomes an administrative burden,” Budri says. “They try to find the time during high demands of clinical time.”
As a licensed APRN, Budri can handle peer-to-peer sessions herself, which has led to some denial reversals. Her job is to show the insurance company why receiving the service offsite is unsafe for the patient. For instance, some patients have a history of allergic reaction to medications, which can be life-threatening.
“Outpatient centers are not equipped to handle that. It is much safer to be in a hospital setting,” Budri says. Even in these cases, says Budri, “I find that if it’s not recent documentation or an event in the last year, they don’t count it. You have to be very high risk for insurance companies to approve it for this reason.”
Another issue payers do not take into account: Most children would rather go to a familiar place for treatment. “What we have found to be disappointing is that the social or mental impact of this recommendation is not considered,” Budri says.
Involving families can make or break the outcome of the appeal. When the parent is the one making the call, says Budri, “the conversation is no longer about money, which it may appear to be when the request comes from the hospital. It’s now about patient preference — and safety.”