$150M in charges paid due to process
Pre-arrival nurse acts as liaison
A new pre-arrival unit at University of Mississippi Health Care in Clinton has revamped the authorization process for services that are pending authorization, reports Sylvia Greer, MBA, associate director of revenue cycle management. The hospital has obtained $150 million in revenue for reimbursable services, she adds, many of which would have otherwise been denied by payers.
The main focus of the pre-arrival unit is to financially clear patients prior to receiving services, says Greer, with staff handling pre-registration, pre-admission, insurance verification, benefit eligibility, and pre-authorization/pre-certification.
In 2011, the pre-arrival unit had a less than 1% denial rate due to no authorization or non-covered benefits, says Greer, with 63% fewer overall denials.
"Previously, authorization work was sparsely performed, resulting in many claims being denied," says Greer. "We have implemented a standardized, quality-driven authorization processes for an ever-changing payer environment."
Tougher criteria
Until recently, the authorization process was fairly simple for imaging services such as CT scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans, but this simplicity is no longer the case, according to Hope Johnson, RN, the pre-arrival unit nurse.
"Payers are now enforcing more stringent guidelines and criteria for authorizing services, including procedures that may be routine," Johnson says.
More payers are using third-party vendors to authorize services, says Greer, which makes the process even more cumbersome. To reduce claims denials, a pre-arrival unit was created, with specific employees working under Johnson's direction. Each employee is assigned to work specific types of denials, such as authorizations, coordination of benefits, and eligibility, which has reduced non-reimbursement of services, says Greer.
Johnson acts as a liaison between the payer and the clinician, in order to obtain clinical information submitted to the payer promptly. "The information may not be in our system, and the nurse in the doctor's office may not easily give it out," she explains. "Once they realize how important it is, they want to be sure the patient is not responsible for the bill."
If the patient has an MRI of the lumbar spine, for example, the payer will want to know the complete history and physical before approving the test, says Johnson. The payer also will want to know that the patient has exhausted all other options, she says.
"They want to make sure the patient has tried everything else prior to getting the MRI: physical therapy, pain management, and medications," she says.
That information isn't always in the provider's medical charts, which means Johnson must contact other provider offices where the patient has received treatment.
If the payer's physician wants to speak with the patient's physician directly, Johnson facilitates this conversation.
"All of the notes may be in there, but the doctor who is looking at this from the insurance company wants to know why the doctor ordered a certain test," she says. "Most of the time when they talk, then the case is approved."
Sources
For more information on processes to obtain required authorizations, contact:
Sylvia Greer, MBA, Associate Director, Revenue Cycle Management, University of Mississippi Health Care, Clinton. Phone: (601) 926-3870. Fax: (601) 926-3903. Email: [email protected].
Hope Johnson, RN, Appeals Coordinator, University of Mississippi Health Care, Clinton. Phone: (601) 926-3802. Fax: (601) 926-3821. Email: [email protected].
A new pre-arrival unit at University of Mississippi Health Care in Clinton has revamped the authorization process for services that are pending authorization, reports Sylvia Greer, MBA, associate director of revenue cycle management. The hospital has obtained $150 million in revenue for reimbursable services, she adds, many of which would have otherwise been denied by payers.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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