Many health plans waived some authorization requirements during the COVID-19 pandemic, but the actual effect on revenue is unclear.
“Despite these good intentions, there is concern that the payers didn’t waive authorization requirements consistently,” says Jonathan Lo, principal and global revenue cycle leader at Deloitte Consulting.
Not all authorizations were waived for the same dates of service, or for all services. Payers acted independently and did not follow a set standard, making it impossible for patient access to track what was waived. “In a rapidly changing environment, with provider and payer staffs both working remotely, this was sometimes challenging to understand and potentially confusing for patients,” Lo notes.
Hospitals are fully expecting to receive erroneous denials that will need to be appealed. “There is also concern that payers will ‘trade off’ denials,” Lo adds.
For instance, payers might have waived authorization requirements, but are going to deny those same claims for medical necessity instead. Many patient access departments tried to obtain straight answers, but found it was next to impossible. “We received different messages from the various payers. Because of this, we did not change our authorization process during this time,” says Jackie Weber, MHA, senior manager of practice operations for patient access at Orlando Health UF Health Cancer Center.
The patient access department at Mount Laurel, NJ-based Virtua Health made the same decision. “We elected to continue business as normal as opposed to navigating the varying insurance waivers,” says Patient Access Director Traci Mulvenna.
Staff review every observation/inpatient encounter twice within 24 hours to ensure authorizations are submitted. “Patient accounting maintains a grid that summarizes the insurance communication,” Mulvenna reports.
Denials are reviewed against the grid to identify opportunities to seek appeals for unfairly denied claims. “That said, our denial rate has gone down, and we were not adversely impacted,” Mulvenna says. Some health plans did not employ enough staff to manage all the calls about authorization waivers.
“Comprehensive denials reporting and analysis will be beneficial as we collectively work to understand the impact of this crisis on reimbursement,” says Kevin Thilborger, managing director in Huron’s healthcare business.
Some payers waived fully insured members, but not self-funded plan members. “There are also differences in Medicare, Medicaid, and commercial insurance, depending on the plan type,” Thilborger observes.
Not all health plans updated claims payment systems to remove the waived authorization requirements. “We expect to see denials, most likely by mistakes due to timing,” Thilborger says.
Health plans might have waived authorization in some cases, yet still deny for “no auth” in place.
“Additionally, true denial types are being masked by use of other classifications. We have reports of ‘non-covered services’ being used as a catch-all,” Thilborger says.
At Norfolk, VA-based Sentara Healthcare’s hospitals, registrars are trained to check health plan portals consistently. If it indicates “no auth required” for a service, no authorization is obtained.
“We are given a reference number to attest to this. But the payer still denies for no authorization, and it is appealed,” says Paul G. Hudgins, director of Sentara Healthcare scheduling and concierge services.
To prevent “no auth” denials during the pandemic, “we follow ‘business as usual’ practices. We follow a series of steps, consistently,” Weber says. Staff have continued to submit requests in a timely manner, based on health plan guidelines, use worklist tools to capture authorizations in real time, and identify if certain documents are missing.
“We provide continuous training in understanding the EMR [electronic medical record], and how to extract the information needed to submit and expedite the authorization process,” Weber explains.
Waivers have not changed the fact authorizations continue to demand way too much time and effort. “The processing time required for prior authorizations sets up a continual race against the clock,” says Christina Harney, vice president of access management at Indiana University Health.
Patient access staff are scrambling to keep up with demand, rescheduling all the postponed surgeries and diagnostic tests. “While authorization timeframes were extended, our team still must ensure they are updated with the payer,” Harney says.
Each case requires, at minimum, confirmation the waiver is in place and approved for the new service date. Fortunately, this does not require the authorization to be filed a second time. “But there is still work to be done to ensure that everything is financially clear for the new date of service and new set of parameters,” Harney notes.
Since each payer’s waiver rules differ somewhat, the team has to check on every case. “The different parameters across all payers force us to reconfirm every authorization,” Harney says.
Delayed patient care is a constant worry. “As we wait for payer determinations, we do what we can to avoid an administrative denial for services,” Harney reports.
Concurrently, staff do all they can to keep the hassles from interfering with patient care. “Prior authorization timeframes are unpredictable,” Harney says. The department has made two important changes:
• Patient access created a clinical review process for patients whose care is about to be delayed because of a pending authorization. A cross-functional team, including physician advisors, works together to ensure all payer requirements are met. “This achieves authorization and supports medical necessity,” Harney says.
Many claims denials have been prevented with this approach. “This, combined with an educated prior authorization team, avoids delays in care,” Harney adds.
• Staff obtain authorizations at the point of scheduling. The authorization process for surgery starts up to one month before the service date, or as soon as services are scheduled. For radiology or imaging procedures, authorizations start about five days before service. “We try to work within these timeframes to minimize reschedules,” Harney explains.
Even with all these processes, there is no getting around the fact that for many patients, authorizations equate to anxiety. Staff reassure patients by stating, “It is our job to watch over this process, and ensure that your insurance company has the information necessary to cover your care.”
Registrars also give many updates to worried, waiting patients. “We make sure to communicate regularly so they know where we are in the authorization process,” Harney says.