EXECUTIVE SUMMARY
Patient access staffs are challenged to work much more closely with providers’ offices to provide payers with required clinical information and to avoid denied claims.
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Route all physician orders to a referral center that obtains authorizations.
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Alert physicians electronically when a diagnosis does not support the services being ordered.
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Have Nurse Auditors Review Any Claim Denied Due To Medical Necessity.
Janice “Mae” Williams, manager of precertification at Memphis, TN-based Methodist LeBonheur Healthcare’s Centralized Services Division, recalls having a “wow” moment during the first week of January 2015. Insurance carriers had put into place more requirements before issuing prior authorization for diagnostic and surgical procedures.
“The rules get more stringent each year,” Williams says. “What amazes me is we can go to the insurance company’s website and do exactly what it says, only to be denied and have them say, ‘We haven’t updated our website yet.’”
Such denials sometimes can be successfully appealed, but this appeal process requires a large amount of rework. “We’ve challenged a lot of them, and some insurance companies will not pay retroactively,” Williams says. “They are now saying, ‘If you don’t get the precert on the front end, I’m sorry, that’s your loss.’”
Commercial payers are “much more aggressive” regarding medical necessity at the time of issuing authorization, as well as during claims processing, according to Mary Lee DeCoster, former vice president of revenue cycle at The Maricopa Integrated Health System (MIHS) in Phoenix, AZ.
Payers are demanding much more clinical information before they’ll give an authorization, and that requirement means providers’ offices need to be involved. “High-cost diagnostics, including MRIs and PET scans, are getting a lot of attention from the medical review perspective prior to service,” says DeCoster. DeCoster is vice president of consulting services for Adreima, a Phoenix-based revenue cycle services firm. Adreima is assisting MIHS with recovering revenue associated with clinically related claims denials.
To obtain authorizations, MIHS created a central Referral Center, part of the ambulatory registration services department. All requests for services are routed from the ordering physician to the Referral Center. “A staff of specialists, with clinical support, work to secure the authorization prior to care,” says DeCoster.
The physicians can rely on the expertise of the Referral Center’s specialists to secure authorizations. “They notify the physician when the patient’s coverage does not include benefits for the service ordered or when the patient must be referred outside of the MIHS,” says DeCoster.
In the health system’s fully integrated Epic system, each patient has one record throughout the system, including clinics, the hospital, the ED, or urgent care. “All of the primary care records are available to the referral specialist,” DeCoster notes.
Orders are entered electronically into the MIHS’ clinical physician order entry system.
“Each order requires a supporting diagnosis supporting the services ordered,” says DeCoster. Rules are built into the Epic system that alert a physician when a diagnosis does not support the services being ordered.
The managed care department gets involved in cases where there are questions regarding contractual terms or requirements. Some claims are successfully appealed based on the clinical documentation contained in the medical record. “Any claim denied due to medical necessity is reviewed by a nurse auditor,” says DeCoster.
In one such case, a victim of a motor vehicle accident was brought to MIHS, which is a Level I Trauma Center. “Initial surgery and stabilization was provided,” says DeCoster. The insurance plan wanted to transfer the patient to another facility because the hospital does not contract with the plan.
“The managed care department was able to negotiate an arrangement specific to this patient,” says DeCoster. “The patient was able to stay at MIHS, ensuring continuity of care.”
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Mary Lee DeCoster, Vice President, Consulting Services, Adreima, Phoenix. Phone: (602) 636-5600. Fax: (602) 265-3693. Email: [email protected].
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Janice “Mae” Williams, Manager, Precertification, Centralized Services, Methodist LeBonheur Healthcare, Memphis, TN. Email: [email protected].
