Clinical information coming into play
Payers are looking at medical necessity
Patient access managers at UK HealthCare in Lexington, KY, are seeing a trend in more stringent referral requirements with a clinical focus. For example, a patient's primary care physician has to be much more involved in coordinating the specialty care of their patients.
"This is particularly true of our Kentucky Medicaid managed care organization plans," says Leigh A. Hunt, patient access manager for ambulatory services and the Patient Access Center at UK HealthCare in Lexington, KY.
One of the main areas the outpatient access department at Danbury (CT) Hospital performs preregistration for is cardiology testing. "We clear an average of 55 to 75 patient accounts daily for echocardiography, nuclear stress testing, regular treadmill stress testing, cardiac rehab, and arrhythmia clinic patients," reports David Hoogenboom, CHAA, team lead/patient access liaison III.
Hoogenboom recently received training on clearing these accounts, in order to be a back-up for the person who is normally responsible for this. "Since then, I have learned so much about the various kinds of tests, as well as Medicare, Medicaid, and commercial insurers," says Hoogenboom. "I am proud of the record we have in our department. We have very few denials."
Extra steps needed
Because Medicare requires services rendered to be medically necessary for claims to be paid, patient access staff members need access to patients' clinical information in the electronic medical record.
"Each service scheduled must have appropriate ICD-9 diagnosis codes, to verify that the service is medically necessary," says Hoogenboom.
In addition, many insurance companies use third-party medical management companies to approve or deny services. "Staff must be properly trained on how to access these resources," he says. "Building a depth of knowledge of CPT codes must be done as well."
Each day, Danbury Hospital's patient access staff send an email to the revenue integrity group on which procedures are scheduled for that day in the cardiac catheterization lab and whether or not these require authorization. "The following morning, another email is sent back to us letting us know if there were any additional procedures that the performing doctor decided to do while performing the original procedure," says Hoogenboom.
The needed for additional procedures, such as angioplasties, stent placements, and ablations often is not apparent until the original procedure is in progress. "The email informs us that we now need to make another call to see if the additional procedure requires authorization," says Hoogenboom. "We then notify the ordering doctor to obtain it, if necessary."