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Auths becoming more numerous and detailed
Payers going 'down to CPT code'
While payers used to encourage registrars to notify them that a patient was hospitalized, they are now requiring it, says Mary G. Lawson, BSN, MPA, director of admissions at University of Louisville (KY) Hospital,.
"Payers are also requiring authorization for high-dollar imaging procedures that they weren't before," she says. "They get very detailed, down to the CPT code." Here are changes that the department made to obtain authorizations:
1. The scheduling system was revamped.
In most cases, the patient arrives with an order, or an order is sent at the time of scheduling, so registrars know exactly which procedure the patient is going to have. "In an ideal world, the authorization would come with the order," says Lawson. "If not, we are setting up our scheduling system so that we know which payers require authorizations for which procedures."
The scheduling system now has specific payer fields if authorization is required for a procedure, she explains, such as CPT code 71250 for a CT of the chest, which will populate the authorization field on the schedule as "Need."
2. Clarification is obtained as to whether the authorization is for inpatient status.
"We have a list of 1,700 procedures that Medicare says are inpatient. Until recently, we had really been following that," says Lawson. "But as we move to more minimally invasive procedures, insurers are now saying that some of these cases need to be outpatient."
Increasingly, payers are denying some claims with inpatient codes, saying they should have been done on an outpatient basis, says Lawson. "Our case manager works very diligently to get those overturned. We enlist the help of the physician as necessary."
To prevent these kind of denials, Lawson says that registrars first verify if a procedure is a covered benefit, and if so, whether it is covered as an inpatient or outpatient.
3. Registrars begin the process five days before the patient's arrival.
"By the time we get to that point, we pretty much know that cancellations are going to be minimal," says Lawson. It also gives registrars enough time to make necessary corrections, such as informing the payer that a procedure is going to be inpatient, she adds.
In some cases, registrars need to contact the physician's office to prod them to initiate the authorization process, as some insurance companies require at least three days to give an authorization, says Lawson. "We may need to tell them, 'Either you start the authorization process today, or we may need to postpone surgery,'" she says.
4. Staff are careful to identify the patient's primary insurance.
While denials related to eligibility total less than 1% of all claims, according to Lawson, registrars still are striving to identify the patient's primary. "Patients may have multiple carriers, and we have to get the primary insurance correct. That can be a challenge," says Lawson. "The patient may pull out two insurance cards and they can't tell us which one is primary."
Registrars use several tools to complete insurance verification, including an embedded product in the Admission/Discharge/Transfer system, says Lawson. "Eligibility denials are usually human error, which occurs when the registrar does not accept what the system is indicating as primary," she says. "This mostly occurs in high volume areas, such as the emergency department."