Do you lack access to clinical information?
If so, claims denials will result
Patient access areas, especially those responsible for obtaining prior authorizations and contesting denials, must have proper access to clinical information, urges David Hoogenboom, CHAA, team lead/patient access liaison III in the Outpatient Access Department at Danbury (CT) Hospital.
When Hoogenboom calls to obtain retroactive authorizations for patients’ tests, insurance company representatives often want to know the results of other recent tests, such as EKGs or blood work.
"It also really helps to be able to view the physician’s note from the day that they saw the patient in the office and ordered the test," says Hoogenboom. "This way you can convey to the payer exactly why the physician wanted that specific test done."
It is very important that clinical staff specify why they are requesting a certain exam, so the patient access staff working on obtaining authorization have the most comprehensive information possible, adds Hoogenboom.
Before Aaron Robison, CHAA, a patient financial advocate at University of Utah Health Care in Salt Lake City, calls to obtain authorization for a service, he makes sure that he has access to the patient’s full chart. "I know for certain that I will be questioned on items ranging from clinical notes to lab results, and imaging reports to pathology findings," he explains. First, Robison goes through the patient’s chart to find all of the most recent and relevant clinical notes and results.
"This helps me greatly, as I can more easily answer clinical questions verbally rather than having to send in information via fax or email," says Robison.
Providing the payer with all relevant clinical data, versus just sending in the past scan or imaging results, reduces the chance that the payer’s nurse reviewer or medical director will deny the request.
"Insurance companies want a full picture of the patient’s care," says Robison. "Instead of waiting to receive a request for additional information, I try to send in all that I have with the initial request."
Clear communication needed
Even the way in which patient access staff word authorization requests can prevent a denial.
"At times when I thought I would get a denial for a service, it was approved — only because I was able to tie that service to another treatment that the patient had either undergone or was currently having done," says Robison.
To prove medical necessity, patient access employees must be able to communicate clearly the need for a certain procedure. "If you call for an authorization and can’t explain why the service should be rendered, chances are the reviewer won’t give you the chance to send in documentation before giving a denial," says Robison.
Robison says patient access employees need to access a patient’s chart electronically to view all relevant clinical information.
"This makes all the difference when initiating a request for services," he says. "It’s when the needed notes or findings aren’t available, or haven’t been done yet, that life gets difficult."