Deborah Herron, AVP of Patient Financial Services at MedStar, describes the rollout of a program to align facility and physicians around the reduction of authorization denials.
What steps are you taking to combat authorization denials?
Deborah Herron: “For MedStar, we have moved toward centralization in the pre-authorization area, where we're bringing all of the authorization needs for both physician and facility into one structure. So we will be clearing those patients for both facility and physician (with the goal) to be paid more timely.
"For the roll out, we started with our areas of most concern, where we were getting no-auth denials. One area was our CPT mismatches and our ASU (ascending urethrogram) procedures. Under this new structure, we tried to tighten up a process, brought in some clinical support to fight some denials that we were receiving, and made sure that as soon as we knew another procedure was performed, then we would be able to secure a retro-auth prior to billing.
"The next areas of focus were oncology and our cardiac procedures––those high-cost areas where you want to make sure authorizations are secured. Procedures have been brought into the scope of the restructure, and, as they are brought on board, operations are improving and new leadership is in place to make sure it's a smooth transition."
Explains Herron on the focus: "Prioritization of oncology, as an example, is because the individuals securing the auth have other responsibilities when they're within the area of the facility itself. If they're in the hospital and they're working in the oncology department, they could have other duties. The authorization where they thought that it started or completed might be left undone or unchecked. If drugs or treatment plans are changed, then there could be a timing delay in making sure that an authorization for a new drug has been secured. Now pulling it out, giving 100% focus on those areas for the system should improve our success in securing those auths on time and getting paid the first time through.
"We have already seen an improvement in our CPT mismatch with our ASU procedures. By inserting the clinical review after the services have been performed but prior to bill drop, the payers that allow us to secure a retro auth have allowed us to do so and those claims are dropping. They're paying cleaner, so that we're not having to fight them on the back side."
