Competing means making things easier for docs
Performing precerts becoming more common
When patient access manager Tom Morris, CHFP, received some requests from physicians to do precertifications on outpatient diagnostic tests that normally were handled by the physicians, he felt the only appropriate answer was "yes."
"In all truth, when [physicians] are precerting a visit, they get paid, but with MRIs and CTs, they're just referring, says Morris, a manager with Promina Gwinnett Health System in Lawrenceville, GA. "I don't blame them for not wanting to do [the precerts] for those."
And perhaps even more to the point, he says, some of the smaller outpatient imaging centers in the area were moving toward performing precerts for their customers. One physician in particular, an orthopedic surgeon, was interested in turning over the precert duties because of the high volume of procedures he referred to the hospital. "I thought, `If we want to be competitive, we need to do this.' Otherwise, he can send [the referrals] to me or to [a facility] that does the precert for him."
Position evolvedThe request came at the same time Promina Gwinnett was experiencing reduced volumes at its psychiatric facility, so the decision was made to reallocate a full-time equivalent to perform the precert function, Morris says. Training was accomplished through a couple of meet ings in the physician's office and some telephone conversations with the physician's frontline staff.
Each morning, the physician's office faxes the patient registration office a list of its patients scheduled for MRIs and CTs, he says, and the insurance verifier calls the appropriate insurance company to obtain authorization.
The pilot project with the orthopedic surgeon's office has been in place for three months and appears to be a success, Morris says.
"So far, so good. The physician's office staff are pleased they can focus their attention on other aspects of their business," he adds. "If the insurance company wants more information, such as what clinical interventions have been made, we refer them back to the physician's office, and they are happy to handle that."
In the past, Morris' staff often would make two or three calls trying to determine if the precert had been obtained so it could be noted on the patient's record.
"The new process has actually eliminated some of the confusion often encountered when trying to call the insurance company or the physician's office to see if the precert has been called in," explains Kimberly Farmer, CPAR, Promina Gwinnett's insurance office supervisor.
"Now that we are responsible for obtaining the precert, we no longer have to waste time making multiple phone calls," Farmer says.
Use caution when expandingMorris' department works with eight orthopedic practices, most with multiple physicians. Therefore, he is looking to expand the precert service, but with caution. "We want to be careful," he says. "For some areas, it's a nice idea but not feasible - it could grow out of control if you included all procedures."
Physician need will drive the process, he adds, noting that few physicians are interested in surgical precerts.
Although his department has not experienced this problem, Morris says he's aware of cases at another facility in which insurers would not allow hospital staff to do the precerts. "It could be contractual - they say it's the physician's job."
But performing this service "is an opportunity for access managers that will go a long way toward building better relationships with physicians. Any [insurance-related] phone call can be a five- to 30-minute nightmare these days. We see a lot of physicians' [staff] holding on the phone to find out if a precert is required. We're trying to eliminate that problem for them."
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