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Staff are in difficult position
It's taken a collaborative effort between patient access and provider offices to navigate the challenges of prior authorization and payer requirements, while continuing to give patients an excellent experience, says Adrienne Pinelle, CHAA, manager of the preauthorization team for patient access services at University of Utah Health Care in Salt Lake City.
The biggest challenge, according to Pinelle, is the turnaround time that it takes for services to be authorized. "Our medical providers' goal is to provide the best treatment and care possible," she says. "They want the patients scheduled for services as soon as there is availability on the schedule."
A patient might be scheduled for surgery in three days, notes Pinelle. In this case, she explains, patient access staff are put in the difficult position of informing the physician and patient that the insurance company will require two weeks to complete the review prior to authorizing payment. "We do our best to work with the departments to keep the provider offices up to date with certain payer requirements," says Pinelle. In this way, services can be scheduled to allow for enough time to complete authorization requirements, she says.
Stay in close contact
Pinelle's staff stays in close contact with the various departments that tend to have significant amounts of services that require pre-authorization or other time-consuming payer requirements. Staff are able to obtain the necessary documentation proving the patient meets the criteria for the procedure, she says.
"University of Utah Hospital is a teaching hospital with new and innovative procedures that are not performed at other facilities," she notes. "Procedures that are not well known or common can be a challenge."
Pinelle says that in these cases, communication and teamwork become especially important. For example, the Cardiology Department has a unique cardiac ablation protocol that is not available elsewhere, she says, but it contributes to excellent patient outcomes. "Because this protocol falls outside of the norm, meeting payer requirements can be very challenging," she says. "We have improved the patient experience and physician satisfaction by holding meetings between our two departments."
Staff members obtained a better understanding of each area's challenges, says Pinelle. "This allowed us to share information. We created an agreed-upon workflow," she says.
Clinical areas now notify the patient access team before the patient is scheduled, says Pinelle. This process gives staff enough time to verify benefits and authorization requirements, and then communicate that information back to the provider. "Helping the clinical team to understand the payer requirements has enabled the clinical staff to be pro-active in providing the necessary clinical documentation upfront," says Pinelle. "This has decreased turnaround time."