Is anyone saying no to uncooperative doctors?
Which access services departments are taking the proactive stance of not scheduling elective services for managed care patients without an authorization? That is the question posed by Martine Saber, CHAM, regional director of patient access services for Baycare Health System in Clearwater, FL.
The issue, she says, is that physicians, who are responsible for obtaining the authorization, often schedule elective surgeries that are not preauthorized. In fact, some physicians simply schedule blocks of operating time for several surgeries and don’t identify the kinds of procedures being done until the day before, Saber adds.
Check with physician’s office
More often, she notes, the problem is that a physician sends a patient with an aneurism, for example, to the hospital for a computerized axial tomography scan of the head. The hospital performs the procedure, which is obviously needed and shouldn’t be delayed, and finds out later the physician has not gotten the preauthorization, Saber explains. The insurance company denies reimbursement, saying it should have been called in advance.
Even trickier, she points out, are cases in which a primary care physician (PCP) refers a patient to a specialist, who then tells the patient to schedule himself for a magnetic resonance imaging procedure. No one gets the preauthorization because the specialist says the PCP should do it, and the PCP responds that he didn’t order the test, Saber says.
"Nobody wants to get it because of the time that’s spent holding on the phone," she notes.
Saber says she would like to know what it takes to establish a ban on unauthorized elective procedures.
"How did [institutions that have instituted a ban] get to that point? How successful are they in doing this, and have they lost physicians as a result? Some hospitals are frightened to [ban unauthorized procedures], saying, We don’t want to upset our physicians,’" she notes. "We’re at the point of saying, We don’t want this type of physician.’"
[Editor’s note: If you have feedback for Saber, please call editor Lila Moore at (520) 299-8730 or send e-mail responses to [email protected]. Saber may be reached at Morton Plant Hospital, 323 Jeffords St., MS#43, Clearwater, FL. Telephone: (727) 462-7139. Fax: (727) 461-8488.]
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