Executive Summary
Payers are requiring detailed clinical documentation for authorizations, but providers’ offices often don’t provide the information in a timely manner to patient access. About one-third of claims require clinical documentation at Conway Medical Center, where denials total $2 million to $3 million monthly. To avoid losing revenue, do the following:
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Compare CPT codes that were done with authorizations that were obtained.
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Get clinical information together before calling for authorizations.
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If A Different Procedure Was Done, Send Or Notes To Explain Why.
Patient access needs excellent processes to respond to payer requirements for peer-to-peer review of the patient’s medical records, says Ketan Patel, a senior manager in the healthcare provider segment of strategy and operations for New York City-based Deloitte Consulting.
“The biggest challenge around this is it requires a significant amount of time and, also, identifying the right resource to provide a timely response back to the payer,” he adds.
If the payer doesn’t receive the requested information, it prolongs the authorization process. This issue could result in postponement or cancellation of the procedure. Lisa Adkins, MSN, RN, CPNP, CRCR, director of patient authorization at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE, says, “Often, this results in the need for a peer-to-peer conversation and/or a letter of medical necessity. Both cause extra work for the provider and the office staff.”
Access staff at Nemours/duPont facilitate the peer-to-peer review between providers and the payer medical directors. “They notify our provider of the denial, obtain information around the reason for the denial, and assist providers in connecting with the medical director as required,” says Adkins.
At Arlington-based Texas Health Resources, access staff sometimes avoid the peer-to-peer review by finding out what payers are missing and getting it to them quickly. “About 25% of the time, we can avoid the peer-to-peer. But some payers are very particular, and no matter what info we give them, they still want it done,” says Lynn Arrington, CHAM, director of insurance verification.
Some doctors are resistant to taking time to do the peer-to-peer review. “We sometimes get pushback from doctors,” says Arrington. “We have seen denials where the doctor’s office didn’t do the peer-to-peer in time.” Physicians sometimes unfairly blame patient access for not obtaining the authorization. Insurance verifiers turn to the department’s physician liaison for much-needed assistance.
“It really does help us out,” says Arrington. “My staff can call the doctor’s office, but when it’s a higher-up person speaking directly to the doctor, it means a lot more.”
SOURCE
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Ketan Patel, Strategy and Operations, Deloitte Consulting, New York City. Email: [email protected].
