It’s not easy to persuade a busy physician to engage in a time-consuming conversation with an insurance company representative. Sometimes, it’s necessary to avoid a denied claim.
“Coordinating with clinical staff is key,” says Brandon McCord, director of the pre-service center at Ochsner Health System in New Orleans.
Michelle Fox, revenue operations director for patient access at Health First in Rockledge, FL, facilitates peer-to-peers in two ways:
- She provides education to admitting physicians on payer requirements for medical necessity determination;
- She works with case management to coordinate the peer-to-peer request.
“The easier patient access makes it for the physician to participate, the quicker the claim will be settled,” Fox advises.
Patient Applies Pressure
In a decentralized registration setting, patient access probably can alert a physician that a peer-to-peer is needed. “In a larger or centralized setting, the job can be much more difficult,” McCord warns. Ochsner’s patient access department uses a messaging system to let physicians know a peer-to-peer was requested.
“When this fails, the request is escalated to patient access leadership, who reaches out to counterparts,” McCord explains. Patients also are involved early. “Numerous times, we have seen a peer-to-peer be approved without the conversation because the patient is applying pressure,” McCord reports.
Richard Garretson, authorization unit representative lead at Kadlec Regional Medical Center in Richland, WA, suggests facilitating peer-to-peers in these ways:
- Let the provider know exactly what’s asked.
“This helps the provider complete the peer-to-peer quicker, without having to regurgitate everything that was already sent to the payer in the initial request,” Garretson explains.
- Find out if the payer will allow the peer-to-peer to be scheduled at a certain time.
“This could help providers be more efficient in completing the reviews,” Garretson offers.
Bypass Requests Altogether
Because of the surge in peer-to-peer requests at Ochsner, “measures have been put into place to alleviate the issue,” McCord reports.
In many cases, the department has avoided the time-consuming requests successfully. Patient access created a clinical review team specifically for this purpose. The team consists of a group of nurses on the authorization team who handle complex clinical services. “They can help with a nurse-to-nurse conversation when needed,” McCord says. “This has proven to be a huge success.”
The team handles authorization requests for infusions, medication injections, complex surgeries, and specialty imaging. “If a rep is having an issue with obtaining an authorization or understanding clinical documentation, one of the nurses jumps in to lend expertise,” McCord says.
To avoid denied claims, clinical documentation is a must. “But it has to be the correct clinical documents,” McCord notes. It’s not enough to simply attach the most recent office notes and imaging if these aren’t relevant to the issue at hand.
“I don’t necessarily mean a full-on chart review by someone who is not clinically trained,” McCord continues. “But the rep should at least make sure it is information related to the diagnosis or issue.”
It’s important not to omit the requesting physician’s notes. “A patient could have four additional different visits before the surgery comes around,” McCord adds. “The submitted documents need to match up.”
Details Matter
Jackie Jordan, MBA, CHAM, patient access/scheduling manager at Kadlec, pays close attention to details when submitting authorization requests.
“If it seems there is information missing in the progress notes, it may help to look at other recent provider visits that are related to the patient’s current condition,” Jordan suggests.
Reading through the provider’s assessment often is eye-opening. “Try and figure out exactly why the provider is ordering a specific imaging study or procedure,” she recommends. Payers especially appreciate the most recent specialty visit notes related to the reason for the test.
“If you track via payer the types of peer-to-peer requests, you can create a list of specific information to send upfront,” Jordan adds. For instance, visit notes from a pain specialist, imaging results, therapy plan of care, and number of treatments completed has prevented many peer-to-peers for claims involving neck pain, Jordan says. “We have 0.8% denials for our controllable write-offs.”
SOURCES
- Michelle Fox, Revenue Operations Director/Patient Access, Health First, Rockledge, FL. Phone: (321) 434-6017. Email: [email protected].
- Richard Garretson, Authorization Unit Representative Lead, Kadlec Regional Medical Center, Richland, WA. Phone: (509) 942-2116. Fax: (509) 942-2036. Email: [email protected].
It’s not easy to persuade a busy physician to engage in a time-consuming conversation with an insurance company representative.
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