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Payer auth requirements shouldn't blindside you
Prevent needless claims denials
Payers are asking for more preauthorizations, even for services that previously didn't require them, reports Connie Campbell, director of patient access of Mercy Medical Center in Oshkosh, WI.
"There are not many areas in radiology that do not require an authorization now, whereas two years ago it was just a couple of them," she says.
Magnetic resonance imaging (MRI), ultrasound, nuclear medicine, and CT scans require authorization, says Campbell. Authorizations also are needed for durable medical equipment (DME), medications, hospital stays, physical therapy, radiology, behavioral health, the pain clinic, and all inpatient surgeries, she adds.
"We need authorization for select outpatient procedures, which I am sure will also turn to all outpatient procedures," she says. "Even some of the Medicaid products are starting to require authorizations, where before they did not."
Registrars find it increasingly difficult to keep up with all of the different insurance company requirements, says Campbell. "We have no software to easily pop up with what specifically is needed for what is ordered," she says. "There is no way to easily translate the CPT and ICD-9 codes for physicians so they can see what is needed."
Needless denials occur as a result of getting the wrong authorization or failing to obtain one that is required, says Campbell. "We considered forming a large authorization department to deal with the new requirements," she says. "But since that project was turning to be out too immense, we decided to focus on obtaining authorizations for the high-dollar radiology procedures."
Otherwise, says Campbell, each office or specialty is responsible for staying current and obtaining the necessary authorizations. "We did start putting the requirements on spreadsheets," she says. "We also try to build in as many cues as we can into our computer systems."
At Valley Health System in Ridgewood, NJ, the information services (IS) department built a tracking system so staff can see what pieces of the pre-registration function are outstanding at any point in time, says Maura Corvino, MSOL, RN, CEN, assistant vice president for emergency services and patient access.
This might be data from the physician necessary for case day, or pre-authorization because the case was scheduled too far in advance to obtain it from the payer, she says.
"Another customization our IS department built allows us to compare the planned disposition for the patient with the requirements by the insurance company," says Corvino. "If there is a mismatch, we can rectify it before the patient arrives." (See related stories on obtaining more authorizations below, and timeframe for obtaining authorizations, p. 66.)
For more information on payer authorization requirements, contact:
Connie Campbell, Mercy Medical Center, Oshkosh, WI. Phone: (920) 312-0002. E-mail: firstname.lastname@example.org.
Maura Corvino, MSOL, RN, CEN, Valley Health System, Ridgewood, NJ. Phone: (201) 447-8301. Fax: (201) 251-3467. E-mail: email@example.com.
Susan Sigler, Valley Health System, Ridgewood, NJ. Phone: (201) 447-8000 Ext. 2778. Fax: (201) 251-3467. E-mail: firstname.lastname@example.org.