Authorization-related denials continue to be among the top denials for organizations. Authorization denials add to A/R days, require work to overturn, and can result in lost revenue. Here’s a list of common pitfalls and possible solutions.
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Pitfall: Unable to stay ahead of incoming authorizations. Last-minute add-ons slip through the cracks.
A two-team, or multi-team, approach to authorizations can help your organization stay on top of authorizations. This approach designates separate staffing teams for handling today’s and the future’s authorizations. “Today” team members verify benefits with payers and determine if an authorization is required for accounts scheduled today or tomorrow. The “Future” team works on accounts scheduled more than 72 hours in advance, with members completing both verification and authorization functions. This team can be further segmented into groups dependent on account volume (e.g., a team who works account scheduled between two to seven days out and a team that works accounts scheduled more than seven days out). This approach allows staff to focus on high-priority accounts, while also prioritizing authorizations based on urgency.
Pitfall: Non-employed physician offices are not consistently securing authorizations. Pre-auth denials are high.
Working with non-employed physicians can be difficult due to a lack of system/IT integration, limited accountability and oversight, and lack of prioritization from physician offices. While a provider’s reimbursement relies on getting a service authorized, referring physicians get reimbursed with or without authorizations. Thus, hospitals have revisited their relationship with physician offices, modifying expectations and shifting responsibilities. In a relationship where hospitals secure all authorizations, an organization and a referring physician make a contract where the organization agrees to obtain the authorization if the physician agrees to provide all necessary clinical information. This streamlines authorization and referral processes for both the organization and physicians’ office. Organizations then obtain authorizations when they need them, ensuring reimbursement for the services it provides. Referring physicians also do not have to worry about time spent securing authorizations and the back and forth it entails. This method is most commonly offered for radiology tests such as MRIs, CTs, PETs, and ultrasounds because they are high-dollar procedures.
Pitfall: Insufficient authorization denials. Problems with authorization workflows.
An important part of combating authorization denials is staff documentation. Some key points of data that staff members should be sure to document include:
- Authorization number or code
- Services and level of care authorized
- Limitations on the scope or duration of the authorization
- Date and time that the authorization was obtain
- Telephone number or the electronic means used to obtain the authorization
- Name of the insurance representative who provided the authorization information
In addition, it’s important to document non-responsive insurance payers, as this will help back-office staff overturn any underpayments or denials.
Hospitals have improved authorization denials by implementing a policy where nurses must sign off on the procedure code. If a code is updated when a nurse is closing a chart, the account automatically goes back to the Authorization team’s workqueue. This helps staff proactively request authorization updates when procedures change, thereby helping to prevent denials and avoiding rework on the back end.
Since Utilization Review teams are often responsible for ensuring authorization requirements are met throughout the length of the patient’s stay, it’s also important to hold regular meetings between Pre-Access Authorization/Admission Support teams and Utilization Review teams. These meetings play an essential role in enhancing communication, building teamwork, and streamlining processes.
Pitfall: Changing payer requirements.
Consider designating a group of staff as insurance experts, who act as liaisons with the Contract Management team, responsible for keeping current on payer polices and create job aides for staff such as a payer requirement matrix. Healthcare organizations have found success in creating an internal newsletter regularly sent to staff with pertinent payer updates, including tips regarding how best to interact with certain payers. Ensure that the insurance matrix is accessible to both Pre-Access Authorization/Admission Support and Utilization Review (as well as all other departments that may need this information, such as PFS or Case Management).