Ensuring Data Integrity and Protecting Your Organization’s Bottom Line


Part IV in this series discusses expanding HIM’s visibility and enhancing organizational processes via authorization denial management.

In my prior article, I discussed the value of payer policy management, and mentioned that “no authorization” denials represent 10-15 percent of all denials. This focused denial category presents another opportunity for health information management (HIM) professionals. HIM can monitor such denials in a process improvement role.

Many organizations perceive denials management as a back-of-the-house process, but all authorizations are a front-of-the house responsibility. For physician practices, denials for lack of authorization represent 80 percent of the total, so working with your hospital-employed providers to avoid such pitfalls by capturing the authorizations required at the time of scheduling the service will mean “cha–ching” – and you know that’s what your CFO wants to hear.

So, what do we need to do?

First: Build off of the work done by the payer policy manager (see my article titled Expanding HIM’s Visibility and Enhancing Organizational Processes: Payer Policy Management). Once we have cataloged the various payers’ requirements, we’ll know which services need prior authorizations. Tie each of those to its designated CPT code.

Second: Access or registration needs to check eligibility for each patient, and when that’s done, checking whether an authorization is required for any planned services should be part of the registration (or, at a minimum, pre-registration) workflow. There are robotics-assisted applications and services available that can assist access in checking both eligibility and securing an authorization. Approximately 23 percent of those responding to a recent survey by Change Healthcare indicated that determining if an authorization was required was the most challenging task they faced. Again, this points to the value of payer policy management.

Third: Remember that building the authorization checking into the workflow may also mean understanding the patient care process, and robots may be deficient in this respect. Don’t stop at getting an authorization only for scheduled services. Obtaining authorizations for anticipated services is just as vital. For example, a surgeon may plan to do a biopsy, but depending on the results, he or she may decide to do a more invasive procedure that also requires an authorization. If that service is done during the same encounter – bang. Denial!

Sitting in access at the hospital should be someone with some clinical expertise, such as a coding professional, who knows that this is a normal chain of events. In the physician office, the authorization specialist can quiz the physician to ensure that authorizations are captured for the commonly anticipated services.

Some inpatient procedures require authorizations as well. Since eligibility may change during a given stay, the workflow for scheduling should include re-checking eligibility throughout the stay, and also obtaining authorizations for any new procedures planned.

Fourth: Teach physicians to document reasons for services likely to be denied, such as screening procedures ordered earlier than the payer’s guidelines recommend due to the patient’s family history; this is an example of something the physician needs to document to support the medical necessity for the procedures. This documentation should be provided when requesting an authorization. Again, this is a documentation improvement education opportunity for a coding professional who serves as an authorization specialist for high-cost tests or procedures.

Fifth: Design edits in the test scheduling and claims billing processes to flag that a CPT code entered requires an authorization. The edit should check to see if there is an authorization number in the designated claim’s field (CMS 1500, field 23; UB04, field 63, etc.). When the field is blank, the scheduler, registrar, or biller should be alerted. Case management may need to be involved to secure authorizations after the fact.

Sixth: Track the denials that arise due to no authorization. Track by payer, CPT®, and physician so that you can update payer policies, build edits for the CPTs, and provide education to providers and their staff in order to avoid denials proactively.

According to an Healthcare Financial Management Association (HFMA) article, up to 65 percent of denied claims are never appealed. Focusing attention on denials for lack of authorization and reducing those denials through process improvement will reduce the labor costs to research and appeal denials, as well as increase revenues – and that’s what we’re going for.

For more information: ensuring data integrity and protecting your organization s bottom line part iv