Executive Summary
Patient access employees often have to make time-consuming phone calls to payers to obtain authorization or inform payers of a patient’s admission.
- Some calls can be avoided by obtaining authorization and verifying benefits online.
- Requests can be grouped by service or payer so multiple authorizations can be obtained in a single call.
- Payer sites often lack a comprehensive listing of CPT codes and related authorization requirements.
Financial counselors at Stonybrook (NY) University Medical Center spend about four hours a day on the phone with insurance companies verifying inpatient benefits and obtaining authorizations.
“The calls are very time-consuming,” says Christine Downey, supervisor of financial services. “We are often on hold for an extended length of time.” Her staff members spend up to 45 minutes on hold, and they spend another 20 minutes getting the needed information.
At OSF Healthcare System’s Financial Clearance Center in Peoria, IL, “hold times for some payers are 30 minutes,” says Jessica Chase, patient access services manager. Sometimes, patient access staff members find out that an authorization never was initiated. “This prompts us to reach out to ordering providers,” Chase says.
Often, employees need to call payers just to verify the receipt of a fax informing the payer that a patient was admitted. Doris Fehrenbach, MS, Stonybrook Medicine’s manager of financial services, says, “Some insurance companies do not acknowledge that fax.” First, employees look for the precertification number on the payer’s website, which indicates that the fax was received. “If it is not there, we have to call,” says Fehrenbach.
Payers also need to be called if a patient is admitted and discharged over the weekend. “Insurance companies refuse to give a precertification even though a fax notification was sent, because the patient is discharged,” says Fehrenbach.
Payer sites are limited
To avoid getting stuck on the phone for hours, Stonybrook’s patient access staff obtain information online whenever possible. “I have never really calculated how much time we save. But it is better than waiting on the telephone,” says Downey.
However, some payer web sites don’t post authorization requirements. “Depending on the web site and the test or procedure, we may be able to get the information needed to effectively document the authorization information,” says Chase. Whether they can do that sometimes depends on whether the necessary clinical documentation has been submitted for the authorization to be initiated.
“Phone calls to payers are often needed to verify benefit information that isn’t provided on the web site,” adds Chase. “Some web sites are more thorough than others.” If pertinent information is missing from the web site, patient access staff members have no choice but to call the payers.
Highly specialized services provided by the tertiary care facility often are not clearly delineated on the payer web site, says Debra Menaker, MPA, senior director of revenue cycle operations at NYU Langone Medical Center in New York City. “As payers add services that require authorization, insurance clearance representatives are required to spend more time calling payers to obtain this information prior to service,” Menaker adds.
Insurance clearance representatives at NYU Langone call payer representatives for these reasons:
- to confirm if an authorization is required;
- to obtain an authorization;
- to follow up on an authorization request;
- to verify out-of-pocket liabilities for an outpatient hospital facility visit.
“It remains difficult to reduce the time spent on the phone,” says Menaker. To save time, the department groups accounts by payer and/or type of service. With this method, staff members obtain multiple authorizations with one phone call.
“The amount of time spent on hold and speaking with payer representatives could be reduced if online portals were enhanced with more detailed benefit and authorization information,” notes Menaker.
For example, many payers don’t provide a comprehensive listing of CPT codes and related authorization requirements online. “This would be a simple way to reduce calls,” says Menaker. “A more robust online portal could offer authorization submissions and responses.”
SOURCES
- Jessica Chase, Patient Access Services Manager, Financial Clearance Center — Outpatient, OSF Healthcare System, Peoria, IL. Phone: (309) 683-3175. Email: [email protected].
- Christine Downey, Supervisor, Financial Services, Stonybrook (NY) Medicine. Phone: (631) 444-7541. Fax: (631) 444-6095. Email: [email protected].
- Doris Fehrenbach, MS, Manager, Financial Services, Stonybrook (NY) Medicine. Phone: (631) 444-7545. Fax: (631) 444-6095. Email: [email protected].
