Many health plans are waiving authorizations for specific diagnostic testing or services.1 Clarity is needed on what exactly the waivers mean in specific cases.

“A lot of wheel-spinning can happen, where somebody gets on the phone and is on hold for half an hour,” says Jack A. Meyer, PhD, an independent healthcare consultant and former principal in the Washington, DC, office of Health Management Associates.

Often, the payer rep cannot really solve the issue. The patient access employee, who has been on hold forever, does not need a policy recited verbatim. What is needed is for somebody to make a decision on whether an authorization is appropriate for a particular case. “Somebody who works for the health plan’s medical director, or the pharmacy and therapeutics committee if it’s a medication at issue, needs to sign off on any deviation,” Meyer explains.

This labor-intensive approach is not going to cut it during a crisis. Instead, says Meyer, “the CEO of the hospital, or certainly a CFO or senior VP — but preferably the CEO, should get on the phone with the CEO of the health plan, boss to boss.”

Then, the two executives could agree on some things, with the hope of avoiding unfairly denied claims. Meyer suggests the hospital CEO could make a case this way: “We argue all the time that we want more money, and you can’t pay for everything. But this is an emergency. Rather than fighting it patient by patient, we need you to authorize a temporary relaxation or even set aside some of these rules, so that our patients in the hospital get what they need when they need it. I am asking you to issue a letter to all relevant staff in a position to make these decisions that until further notice, please relax the rules and allow these claims to be approved.”

“The help has got to be top-to-top, and then top-down,” Meyer adds.

REFERENCE

  1. America’s Health Insurance Plans. Health insurance providers respond to coronavirus (COVID-19). April 24, 2020.