Stop surge of denied claims due to payers’ new clinical requirements
Executive Summary
Patient access areas need revamped processes due to new payer requirements for detailed clinical information, to avoid a sudden increase in claims denials.
• More peer-to-peer reviews are required.
• Payers want documentation that less costly alternatives were tried.
• Providers’ objectives for tests are being reviewed more closely.
Obtaining auths can feel like a trial’
Payers are asking for much more detailed clinical information and questioning the reasoning behind decisions made by providers, before giving authorization for costly diagnostic tests, report patient access leaders.
"Payers are performing a comprehensive clinical review for many service lines, including advanced imaging and cardiology," says Michael Prazniak, assistant director of pre-access, patient access, and patient financial services operations at Florida Hospital in Orlando.
Commercial payers are requiring "more and more" clinical information to support the doctor’s decision to order a specific test, says David Hoogenboom, CHAA, team lead/patient access liaison III in the Outpatient Access Department at Danbury (CT) Hospital. Here are recent trends in payer requirements:
• More payers are requesting peer-to-peer reviews for advanced imaging areas, particularly oncological positron emission tomography (PET) scans.
"In addition to a more in-depth clinical review, the sheer volume of services and number of payers that now require authorization for those services has increased," Prazniak says.
Medicaid requirements for prior review for imaging have significantly increased the authorization team’s workload. "Trends seem to be fairly consistent based on which peer review organization the payer employs to perform clinical assessment, when applicable, as opposed to the individual payer itself," Prazniak adds.
• Payers are no longer satisfied with recent clinical progress notes.
"We are now seeing more requests for lab and lower-level imaging results, past treatment plans including several months of therapy or pharmaceutical interventions, EEG and EKG readings," says Prazniak.
• Payers are reviewing more closely what objectives will be satisfied by the test for which the authorization is being requested.
Payers often suggest alternative services after their clinical review and communicate with physicians about possibly altering the test being ordered, says Prazniak. For example, if a provider orders a CT scan with and without contrast, a payer might suggest it be done with contrast only.
• Payers are suggesting patients go to preferred facilities for testing.
"Payers are now steering patients to their preferred freestanding facilities, after we have been able to receive a clinical approval for a test based on medical necessity," says Prazniak. This step has increased the number of cancellations the department is experiencing, he adds.
• Lab-based sleep studies are receiving much more scrutiny.
"More and more payers are authorizing home-based studies as the first diagnostic course," says Prazniak.
• Payers are asking for documentation that less expensive alternatives were tried first.
Before approving a higher-priced test, such as a nuclear stress test, payers are requiring that the patient must first have a lower-priced test, such as a regular treadmill stress test. David Hoogenboom, CHAA, team lead/patient access liaison III in the Outpatient Access Department at Danbury (CT) Hospital, says, "This is the most common trend I am seeing."
Nurse reviewers not only want to know if other testing has been done that is more inexpensive or less complex than what is being requested, says Aaron Robison, CHAA, a patient financial advocate at University of Utah Health Care in Salt Lake City. They also want to know specifics as to why the provider has chosen a particular test versus less expensive alternatives.
"In some instances, it can feel like a trial of sorts, depending on the insurance carrier," says Robison. "They are trying to find just cause’ and proof’ that the requested procedure will result in a positive outcome that will aid the patient’s care."
Capture relevant information
Patient access areas at Florida Hospital in Orlando have made these changes due to payer requests for clinical information:
• Patient access staff provide questionnaires to physician’s offices.
The questionnaires ask for this information:
— previous or more conservative treatment that has been tried;
— the diagnosis or condition that is being ruled out by the requested service;
— how the outcomes of the requested service will alter future treatment plans.
• Patient access areas provide scheduling areas with a "payer matrix."
This matrix lists all contracted payers and the amount of time that each takes to make a clinical determination on authorization, from the point of receipt of clinical documentation.
"This allows them to schedule patients far enough in advance to allow the payer to review and complete the determination process," Prazniak says. This step reduces the number of rescheduled appointments due to a pending authorization status, or denials after the service is performed.
• Patient access staff perform medical necessity screening at the point of registration.
"This determines if any waiver or ABN [advanced beneficiary notice] should be obtained for potential non-covered services," says Prazniak.
• Patient access leaders participate in quarterly Joint Operating Committees with payers, medical management, patient financial services, and the managed care department.
"We discuss departmental and physician concerns, changing requirements, and clinical and financial performance from both sides," says Prazniak.
Problems with individual claims are sometimes brought up, for more timely resolution by payers.
"We have been able to solicit examples of cases where physicians state they are following clinical guidelines, and yet still receive upfront denials," says Prazniak. (See related stories on obtaining access to clinical information, below, and educating providers on payer requirements, p. 64.)
- David Hoogenboom, CHAA, Team Lead/Patient Access Liaison III,
- Outpatient Access Department, Danbury (CT) Hospital. Phone: (203) 739-8200. Email: [email protected].
- Michael Prazniak, Assistant Director, PreAccess/Patient Access/Patient Financial Services Operations, Florida Hospital, Orlando. Phone: (407) 200-2305. Fax: (407) 200-4984. Email: [email protected].
- Aaron Robison, CHAA, Patient Financial Advocate, University of Utah Health Care, Salt Lake City. Phone: (801) 587-4483. Fax: (801) 585-1296. Email: [email protected].
