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Until recently, an urgent care clinic continually sent patients to St. Nicholas Hospital in Sheboygan, WI, for radiology tests that weren't authorized, reports patient access manager Robyn Rogers.

"This was causing a great deal of conflict between the hospital and the clinic," she says. "As we weren't a continuation of an urgent or emergent visit, but rather, an outpatient hospital service, we needed to ensure that authorizations were in place before performing these tests."

Patient access leaders finally had a conference call with the clinic managers and agreed to allow the tests to be performed, if the clinic assured them that the authorizations always would be obtained. "We agreed to continue this practice, as long as we didn't receive any denials," says Rogers. "This was over a year ago, and it has been working quite well."

Although there wasn't a difference in the denial rate, the amount of work needed to follow up on authorizations decreased, with patient access staff spending much less time contacting insurance companies and physician's offices, says Rogers.

Patient access leaders recently arranged for the clinic to expand this practice to include tests ordered by physicians during scheduled office visits. "They were very happy to follow the same practice," says Rogers. "Patient access now has a much better relationship with the clinic."

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Authorization for elective services sometimes isn't obtained because there isn't enough time between the receipt of the reservation and the requested date of service, says Marsha Kedigh, RN, BS, MSM, director of admitting/ED registration/discharge station/insurance management at Vanderbilt University Medical Center in Nashville, TN.

"There may not be enough clinical notes in the patient record to support the admission, surgery, or procedure," she adds. "The fact that not all insurance companies have the same requirements for authorizations adds to the problem."

Some payers now require certain criteria to be met before an imaging procedure is ordered, such as the patient obtaining an X-ray before a CT scan is authorized, says Rogers. At Vanderbilt, the clinic is responsible for obtaining the pre-determination before insurance management staff can begin their pre-authorization, says Kedigh. "Providers may add CPT codes after the pre-authorization is obtained, or may change the patient's admission status during the pre-authorization process," she says.

Kedigh recommends keeping clinic schedulers and physicians informed on payer requirements for authorizations, such as clinical and referral notes.

"Educate them as to what is needed and when it is needed," says Kedigh. "Different payers have different guidelines for the content they need and for how long it will take to provide a response for authorization."