Relaxed authorization requirements sounds like great news. However, payers are vague on the specifics.
For this reason, some patient access leaders are erring on the side of caution and continuing to secure all authorizations per usual protocol. “The same diligence taken pre-COVID should continue to ensure all necessary authorizations are obtained and denials prevented,” says Laura Burton, director of patient access centralized services at Marriottsville, MD-based Bon Secours Health System.
Here are some issues patient access is seeing:
• In many cases, hold times with payers are ridiculously long. One recent authorization took three hours and 20 minutes to obtain. It normally would have taken about 20 minutes.
“Having these examples documented can help fight denials,” Burton offers. “We’re proving that due diligence was done, but that it was not possible to navigate within the payer constraints.”
• Some payers temporarily waived the clinical review process for certain services. When the claim actually is submitted, though, it is anyone’s guess if the health plans will follow their own rules. Relying too heavily on the waivers “may result in a higher-than-normal number of medical necessity denials,” says Karan Levering, CHFP, assistant vice president of pre-access services at Bon Secours Mercy Health in Cincinnati.
• Claims denials for COVID-19-negative patients are under close review to see if there is any basis to appeal them. Some patients present with COVID-19-related symptoms, but test negative, and are discharged with another respiratory-related diagnosis such as bronchitis.
“The order and documentation needs to clearly define that the patient was being tested for COVID-19, and that it was medically necessary,” says Tammy Stone, BA, CHAM, CRCR, vice president of patient access and clinical services at Ensemble Health Partners, a Blue Ash, OH-based revenue cycle consulting and solutions provider.
Otherwise, health plans could refuse to pay claims for people with negative tests. Since the patient cannot be billed for his or her liability, the hospital could end up with no payment at all.
To protect against this possibility, “registrars are respecting the cost-sharing-waiving enacted by our state legislators for any patient presenting for COVID testing, especially in our emergency departments,” says Sarah Dresch, senior director of patient access for Ardent Health Services’ New Jersey facilities.
The worry that health plans will deny reimbursement for evaluation and testing of COVID-19-negative patients is legitimate. “I have personally experienced workman’s compensation denying claims for patients who tested negative,” Dresch reports.
For patient access, a full list of the approved ICD-10 codes for services where cost-sharing is waived is important so co-insurances, deductibles, or copays are not collected. “Patient access should be working with the back end so they are aware that these balances should be written off after the insurance pays,” says Kathy White, AVP of virtual utilization review and bedded insurance authorization at Ensemble Health Partners.
• Patient access should keep close tabs on all payer updates. Waivers of requirements apply only to specific services, circumstances, and time frames. Successful appeals of claims denials can hinge on proving that at the time of service, the usual requirements were waived.
There is a simple reason why the waivers cannot be counted on: “Not all of the insurance companies will be able to update their systems for the codes that do not require prior authorization,” Stone explains.
• Many payers claim to have relaxed authorizations for “most” or “many” services. What “most” or “many” means is anyone’s guess. “Claims still require the same diligence in reviewing authorization requirements that were in place pre-COVID,” Stone says.
The bottom line is that payer announcements could end up as more of a trap than a time-saver. “Don’t take the bait,” White offers. “Taking advantage of the payer leniencies for no authorizations may delay claims processing and cash flow in the long term.”
For patient access, the safest bet is a “business as usual” approach. If no authorization is in place, health plans may take time to retrospectively review the entire record for medical necessity. “Also consider the amount of internal resources needed to process the medical records and appeals,” White adds.
The alternative is to set normal authorization processes aside and go by the relaxed requirement rules. Hospitals risk increased accounts receivable days and the hassle of appealing denied claims. “This would be very problematic at a time when hospitals need claims to process cleanly and quickly,” Burton says.