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Strategies to increase your preauthorizations
One hundred percent of scheduled cases authorized - that is the goal set by Boston-based Massachusetts General Hospital's financial access unit.
"If we don't have an authorization and referral for anything that is scheduled, and if it's not going to be postponed until we do get the authorization, then it has to go through an escalation process," says department manager Joe Ianelli.
The department uses two primary tools to ensure prior authorizations are obtained: One is a "48 hours" list, and the other is a "bill hold."
The "bill hold" involves accounts that have been discharged but that still lack authorizations. "This is typical for emergency admissions, as insurance companies may request clinical documentation as they are working on their authorization process," says Ianelli. "Technically, we should have no elective accounts on the bill hold, as our standard is to ensure authorization before the visit takes place."
As for the "48 hours" list, "anything that's been in-house longer than two days without an authorization gets really close scrutiny," says Ianelli. "If it's an elective procedure - meaning scheduled - we really have to have the authorization all sewn up before the patient even gets in the door."
Typically, the delays involve patients admitted via the emergency department who haven't yet been authorized. If the authorization isn't obtained for whatever reason - the patient's physician booked the procedure late in the process, or there are difficulties with the insurance company - an escalation process is used. "We get the chief medical officer involved, and they have a discussion physician to physician about whether the case should move forward," says Ianelli.
However, most physicians "want to do the right thing financially and clinically for everyone involved," says Ianelli. "And if they can't justify the case as emergent, they will be amenable to postponing the procedure. We do take the clinical imperative as the priority. "
At North Shore-Long Island Jewish Health System, patient access has increased the percentage of times that staff secure authorization for scheduled hospital services from about 75% of the time to about 95% of the time.
"This has measurably reduced our denials and back-end rework, and has had a positive impact on our agings and cash flow," says Frank Danza, vice president of revenue cycle management "Equally as important, we have been able to isolate those scheduled cases where the payer is unwilling to provide an authorization for an inpatient level of care, before the patient receives the service."
This allows patient access staff to work with the doctor both before and on the day of service to make sure that he or she has documented the clinical rationale for the admission in the admitting order and related notes. "We expect to see a measurable decrease in inpatient denials and resulting downgrades to outpatient reimbursement levels during 2009," says Danza.
Financial rounds meeting is key
Massachusetts General's patient access staff attend a weekly "financial rounds" meeting every Wednesday at 10 am, to review the status of all outstanding authorizations. "This is something I've been doing every week since I got here seven years ago," says Ianelli.
Attending the meetings are a supervisor and two team leads in the insurance group, and two supervisors and one team leader in the financial counseling group, as well as all frontline staff. "We are one contiguous group, and we talk to each other a lot," says Ianelli. "We have SharePoint sites where we post policies and procedures so people don't have to have their own libraries - it's all right there for them."
Ianelli says that of the three major payers in Boston, two are now saying there could be significant changes in their authorization processes. The constant changes, he says, mean that "I need really smart, responsive staff."
The "financial rounds" meeting is based on the model of medical rounds done by physicians to discuss their patients as a group. "I do the same thing here financially. I want to know what's going on with cases that haven't been posted yet, that don't have authorization," says Ianelli. "We have literally everyone in the room, and I go around one by one."
First, Ianelli goes around the room to ask the insurance verifiers, "Who's on the 48-hour list that you haven't been able to post?
"And I want to hear the reasons why," he says.
The purpose isn't to intimidate staff or put anyone on the defensive - it's to solicit ideas to get to the bottom of how the authorization can be obtained. "If there is a tough motor vehicle accident and somebody isn't responding, somebody may say, 'Have you tried calling the police station?' or 'Maybe we should get legal involved,'" says Ianelli. "We try to use a team model approach to get the authorization."
Staff appreciate getting feedback on tough cases from other members of the team. "I think at first, the staff felt nervous going to a meeting like that, but over time they felt really supported," says Ianelli. "Everyone is in on the decision, and people who have been doing this for a long time can share their knowledge. We have been working this way for a very long time."
For each case, Ianelli hears from the financial counselors as to whether the patient is already admitted or is coming electively, and whether he or she is self-pay, a pending Medicaid authorization, or otherwise. "I want to hear where we stand on the process - is it a done deal? Do we need to postpone?" he says.
Financial counseling staff can help move the process along for the most difficult cases. "If my insurance verifiers are having a hard time because there are some insurance issues, then we can get financial counseling involved at the earliest possible stage, so that we can possibly help the patient to apply for public benefits or to set up payment plans," says Ianelli.
Denials are learning tool
Ianelli says that if a claim is denied, the insurance team supervisor, Ianelli's direct report, is the one who handles the appeals. "So when we mess up, we are responsible for trying to fix it," he says. "The clinical appeals are of course handled by case management, but the technical denials come right back to haunt us."
For this reason, Ianelli says that he tells staff, "'Deal with it now or it's going to be a ghost - it will come back to haunt you. So if it slides by and I don't hear about it, it's going to come back and it will be worse.'"
Denials are used as a learning mechanism. "We do 65,000 to 75,000 cases annually, and over 6,000 cases a month, with about 15 people, so it's a huge work volume," says Ianelli. "Sometimes, it's hard to get at the root cause of where the problems are."
The patient access supervisor has to figure out where the fault lies. For example, "Is Payer X acting differently? Did something change over at the payer or do we have a staff member who is making mistakes?"
"We certainly push back with the payers, and payers typically respond if they're at fault," says Ianelli. "We make sure to develop a case on why we should get paid. Sometimes, quite frankly, we have to fall on the sword and tell them that there was an error but we want to get paid anyway. They may say no, but it does happen."
With the large volume of cases handled by the department, it's inevitable that something will fall through the cracks occasionally. "A new staff member may miss the secondary payer, for example, or a coordination of benefit issue will happen from time to time," he says. "But as long as somebody is committed to being error-free, I think everything falls into place."
Ianelli says that when he first joined the organization, he needed to make a decision about the direction the department was going to go in. "We made a strategic decision to have some turnover to get the people in that could do what we needed them to do," he says.
Ianelli adds that unlike many patient access departments, his doesn't have issues with morale or turnover - something he attributes, in part, to the team model and supportive environment he fosters. "In terms of financial staff, we have a nice long period of stability for I'd say, about three years," he says. "If people are leaving, they tend to be wanting to stay in the industry and go to nursing school. We do have somebody right now who will go part-time and still work."
The department has not had to face budget or staffing cuts, reports Ianelli. "We are really lucky so far," he says. "We report right up through the CFO, and she has a good sense of what is needed down here. And on the flip side, if she does ask a department to cut its budget, she makes sure that her departments are cut equally."
Over the past seven years, volume has grown significantly at the organization, but Ianelli has only asked for one additional FTE. "We don't just try to throw bodies at a problem - we run pretty lean here in the financial counseling and insurance groups," he says.
Success, whether with obtaining 100% authorizations or improving registration accuracy, "all starts with the interview," says Ianelli. "If you don't get good people in, everybody's going to end up miserable," he says. "Early in my career, I really hired badly and it's so much more work. And if you don't set the limit and get rid of people who aren't showing up and doing a good job, then you're not doing your job as a manager."
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