Eliminate costly gaps in your authorizations

It sounds fairly cut and dried: If an authorization isn't obtained from a payer, the claim will be denied. However, payer requirements are getting more and more complex and stringent.

"More plans are requiring authorizations that were not previously required," says Helen Thomas, manager of financial counseling at MUSC Medical Center in Charleston, SC. "More and more procedures are now requiring authorizations where they were not required in the past."

Payers also are asking for more documentation to be provided upfront before they authorize a service. "It is not always readily available," says Thomas. "It can require the use of many hospital systems to secure what is needed by the carriers."

Both diagnosis and CPT codes often are requested for processing, which typically are not readily available. Also, with the move to privatizing government payers, HMOs for Medicaid and replacement plans for Medicare want authorizations on procedures that were not previously required.

"That in itself takes more time in the work day," says Marlene Haselden-Mizell, manager for patient access services at MUSC's main hospital.

The patient may also come in with one planned procedure, and while services are being provided, an additional or new procedure is performed. This impacts the authorization number. Another challenge involves patients coming in with a number of different insurances, with each plan requiring something entirely different.

Here are some strategies implemented in MUSC's patient access department to close "gaps" in the authorization process:

• Authorizations are obtained for "add-ons."

At MUSC, one of the biggest challenges for patient access services/registration is the last-minute "add-ons" for radiology and interventional radiology. Procedures may be scheduled on the same or next day, while most insurance companies require a minimum of 24 to 48 hours to secure the authorizations.

"Depending on the time of the procedure, financial counselors may not have seen the request," says Lisa Cooper, manager of patient access services for ART/emergency department. "Several insurance companies require that you go through a third-party vendor for authorizations." Most of the third-party vendors require 72 hours before authorization can be obtained.

In this scenario, the patient has one of three choices. He or she can postpone the test or procedure until authorization has been obtained. This can be a problem for patients if they live out of town or require additional lost time from work. Or, they can wait while a financial counselor tries to obtain the authorization, which puts the technician or physician behind schedule. Lastly, they can pay out-of-pocket.

"None of these solutions make for a 'wow' customer service experience for our patients and staff," says Cooper.

• More frequent updates are given about payers.

"We are meeting monthly to keep staff informed of the changes in insurance requirements and updates from carriers," Haselden-Mizell says.

• A system is in place for length-of-stay changes.

The patient may be an outpatient at the time of admission, but this can change to observation status and then to inpatient status. Thus, a new authorization is required.

• Staff communicate with various departments within the hospital.

This is to ensure they're aware of the various time requirements of the insurance companies as they schedule appointments, says Haselden-Mizell.

• Claims denials are evaluated.

"We determine why the case did not get authorized and how to fill that gap so it is not repeated," Thomas says.

[For more information, contact:

Helen Thomas, Manager, Financial Counseling, MUSC Medical Center, 169 Ashley Ave, Charleston, SC 29425. E-mail: thomashm@musc.edu.]