Prior Authorization Denial Challenges for an Integrated Health System

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1 Prior Authorization Denial Challenges for an Integrated Health System Focus Paper Mathew Smith, MPH, FACMPE August 30, 2017 This paper is being submitted in partial fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives.

2 PRIOR AUTHORIZATION DENIAL CHALLENGES 2 Introduction The purpose of this paper is to illustrate the challenges created by payers with the requirement of prior authorization for outpatient surgeries. A prior authorization is a process that is required by commercial and certain forms of government insurance for a variety of healthcare services. The payer requires that the requesting clinic or hospital call or go through an online portal to request authorization. The payer must approve the procedure in order for the procedure to be paid. If it is done without approval then payment will be denied. The objective of this paper will be to outline the many challenges and burdens that are presented with the need for prior authorizations, and to demonstrate possible solutions for long term financial sustainability. This will be addressed through a literature review around claim denial management and prevention in relation to prior authorizations. Furthermore, the author s personal experience in a large integrated health system developing procedures for the prevention of outpatient surgery denials over the course of a year is reported. Lastly, there will be recommendations for successful ongoing prevention of claim denials leading to long-term financial sustainability. Background and Literature Review A denial can be defined as the refusal of payment for healthcare services from insurance companies to the provider. ( Denial of Claim, 2017 ) Any sort of lack of revenue is detrimental to any practice or health system in today s costly healthcare arena. Denials can result if a procedure is not approved through the prior authorization process, or the correct Current Procedural Terminology (CPT) code is not billed. The CPT codes are numbers that are associated with all procedures and have payments attached to them from the payers. Insurance companies require the CPT code for the procedure to be given at the time an auth is requested. There are several thousands of these numbers, and many of them have small variances which makes knowing the correct code before the surgery very difficult. The focus of the paper will be centered on prior authorization and denials that stem from the lack of authorization. However, there are several types of denials listed below.

3 PRIOR AUTHORIZATION DENIAL CHALLENGES 3 a. Registration b. Duplicate claims c. Non-covered services d. Missing data e. Not enough documentation f. Authorization/pre-certification g. Medical necessity h. Medical coding i. Timely filing j. Coordination of benefits Denials are one of the most costly revenue cycle issues affecting all medical practices and health systems. This is going to continue over the next several years and every practice and health system will forfeit revenue to claim denials. The goal will be to minimize the amount of revenue lost to denials. A study from Becker s Hospital Review revealed that 3% net revenue loss is caused by denials ( The Right Approach 2014). Furthermore, almost 50 % of all denials can be attributed to registration errors, lack of prior authorizations and non-covered services. The costs of denials from lack of prior authorization can be direct or indirect. Hospitals and physician groups often have large staffs that work claim denials and attempt to get the insurers to pay by resubmitting additional medical records, correcting claims, and any other means that will overturn the claim denial. Sometimes these appeals go as far as peer reviews where health system physicians are brought in to argue their case with the payers for the medical necessity of a procedure. A large Florida health system reported that registration and billing staff can spend up to 9 hours per week on hold with payers. Subsequently, the cost of rework is 25 dollars for almost every claim that has to be resubmitted. Furthermore, another study from Health Affairs indicated that physicians on average spend $89,000 of their time per year with insurance

4 PRIOR AUTHORIZATION DENIAL CHALLENGES 4 plans. Subsequently, that equates to about $69 billion annually across the nation. A survey from the AMA reported that 78% of physicians say that eliminating prior authorization hassles is very important ( The Right Approach 2014). Therefore, it only makes sense to prevent claim denials before they occur. There have been many attempts at streamlining better processes to prevent outpatient surgery denials from occurring. However, it is an uphill battle because the amount of time it takes to implement an effective system is countered by the ever-changing policies of the payers. Adding to the issue is that payment policies are not standardized across the multiple payers. What is required for one payer is unique, and they all develop their own policies with minor intricacies that complicate the authorization process further. A high level example would be one payer requiring authorization for a certain procedure and the other not requiring authorization ( Optimizing the Prior Authorization 2017). A large prominent health system in Texas outlined their issues with prior authorizations and claim denials in a recent round table discussion. The Vice-president of Revenue Cycle stated they had an efficient process a few years ago but now with all the payers changes, what was once effective is no longer effective for denial prevention. However, in discussions with payers, they indicate the goal is not to create hassles but to promote efficacy and patient safety. Also, the payer industry claims to hold down costs for the healthcare system ( Optimizing the Prior Authorization 2017). The next section of the paper will discuss the specific burdens for an integrated health system caused by the prior authorization requirements. The Problem The author s health system had been tracking claim denials related to lack of prior authorization for outpatient surgery for the last calendar year and determined it was a major concern. The health system has four communities and they are made up of all the clinics, hospitals, and other healthcare facilities that reside in a jurisdiction. The communities are divided by location and they are the West, East, North Central and South Central. In the community being

5 PRIOR AUTHORIZATION DENIAL CHALLENGES 5 discussed (West), they were experiencing nearly $500,000 per year in lost revenue due to denials related to prior authorizations. The author was asked to lead a large project team to address the problem. The team was made up of several members from different departments as follows: Director of Clinic Operations Executive Director of Revenue Cycle. Director of Central Coding All Surgical Specialty Practice Managers Business Service Leaders from Revenue Cycle The project team met every Wednesday and discussed the denials that had hit the denial report from the previous week. The denial report came from the claims team and it was distributed every Monday for review. It was discovered through reviewing the report that the biggest problem was the CPT code being billed not matching what was authorized. There is a centralized team that does the billing for the clinics and hospital. The process was that the coder would code the procedure in order for the claim to be submitted to the payer and send the code to the billing team. The billing team would enter the codes from the coder and submit the claim to the payer. The clinics within the health system do not have CPT coders in the clinic and it is a financial counselor who obtains the prior authorization for any services/procedures requiring this. One of the challenges of this process is that payers require a CPT code to be provided for the procedure for which authorization is being requested. The financial counselor is an entry level position and is the staff member who explains the patient s benefits prior to their procedure. The financial counselors do not always have the knowledge required to make informed decisions about the correct CPT codes to use to obtain the authorization. Often, the CPT code that was used to obtain the authorization did not match what was actually billed, therefore creating the denial of the claim. While this seems to be an issue that is easy to fix, there are many complexities as to why it

6 PRIOR AUTHORIZATION DENIAL CHALLENGES 6 was not so easy. The major areas of challenge that were identified by the project team were the following: The procedure changing during surgery, which then triggers a change in CPT code is the most common reason that the CPT code being billed does not match the CPT code being authorized Retro authorization is a window provided by certain payers to allow the provider to amend an authorization in the event the authorization does not match what is billed. Not all payers offer this window and several are moving away from this method. Requesting a retro authorization still requires handling by a staff member, so it is not a good remedy. Inability to authorize a range of codes Inpatient only CPT codes Registration errors Medicaid Different coders doing professional billing and hospital billing and lack of coders in clinics result in different CPT codes billed Non integrated Surgeons Procedure changing during surgery This area accounted for the majority of the reason authorizations were not matching what was billed; therefore creating claim payment denials. There are certain payers that give little to no window to amend an authorization. Essentially the healthcare facilities are tasked with being predictable in an unpredictable environment. An example would be asking an OBGYN clinic to authorize the correct CPT code for a hysterectomy when the CPTs are based on the size of the uterus. This is difficult to determine from looking at an ultrasound and certain payers will deny payment for the claim if the wrong code was authorized based on weight. Another example is any case that is diagnostic and the surgeon is determining what he/she is doing once they are in

7 PRIOR AUTHORIZATION DENIAL CHALLENGES 7 surgery. It is almost impossible to know what CPT should be authorized in that situation and, again, certain payers provide no window for a retro authorization. Inability to authorize a range of codes The concept of authorizing a range of CPT codes can be applied to the previous mentioned example of authorizing hysterectomy procedures. A challenge with a few payers is that they will not allow a provider to authorize multiple CPTs for these procedures. Conventional wisdom would suggest that an easy fix to this process would be to authorize all CPT codes that could be possible with the procedure. However, most payers will not let the practice or facility authorize multiple procedure codes. Subsequently, this challenge puts the practice and hospital at a risk for being wrong on their authorization request and having their claim for payment denied. Inpatient only CPT Codes Another problem that was identified by the project team was that there are times that a CPT code is deemed by a payer to be an inpatient only procedure. Therefore, if it is authorized as an outpatient surgery the claim is then denied due to lack of correct authorization. Essentially, there has been an inpatient CPT code authorized for an outpatient procedure. The payers do not indicate that it is an inpatient only code when authorizing and therefore it is the responsibility of the authorizing party to authorize the code correctly. There is a list of these CPTs provided from Medicare, but it is cumbersome in the sense there are over 1,750 codes deemed inpatient only. These are not as frequent as the change in CPT, but would require an extra step in an already complex process of ensuring the correct codes were being authorized. Registration Errors Registration is the beginning of every successful claim that is sent out and every claim that is rejected/denied. There were several instances where the wrong insurance was entered/loaded for a patient, or the patient s insurance had changed between their initial visit and the time of surgery. These occurrences were heavily skewed toward the Medicaid population. One example is the patient s procedure was authorized initially with commercial insurance but

8 PRIOR AUTHORIZATION DENIAL CHALLENGES 8 then the patient switched to Medicaid due to changes in their financial status. The issue here is that there was no authorization given by Medicaid, which would later result in a denial when Medicaid was billed. Medicaid Medicaid presents a unique challenge in two different ways. The first challenge is that Medicaid requires a valid referral from a patient s physician on file for the date of surgery in conjunction with the actual authorization. The referral requirements are that it comes from the primary care provider that is registered in the state s Medicaid system. The state s Medicaid system requires that the primary care provider on the referral match what is registered in their system. This is an issue because if the patient switches primary care providers (PCP) between the time of visit and the surgery then the referral and authorization are considered invalid and the claim will be denied. Furthermore, the authorized service/procedure has to be in the allotted time frame for the patient to receive services on the referral. Referral time frames can range anywhere from 3 months to a year. Some challenges that arise with this is that if a surgery is rescheduled then it may fall outside of the referral s allotted time frame when the Medicaid beneficiary can receive services. Additionally, the referral must have the provider s National Provider Identifier number (NPI) and not the group NPI or it is considered invalid. The NPI number is a unique 10 digit identification number issued to healthcare providers from the Centers for Medicare and Medicaid Services. The second major challenge is that Medicaid s remittance codes do not always accurately reflect why they are denying a claim. Remittance codes are the reasons that a claim is being sent back denied to the provider and they have various categories. Some examples would be no authorization, medical necessity, and exceeds fee schedule. Almost all Medicaid denials come back with the code stating that it exceeds the fee schedule, including those that are denied for lack of valid prior authorization. This makes managing and working these denials nearly

9 PRIOR AUTHORIZATION DENIAL CHALLENGES 9 impossible because of the sheer volume that comes back under this vague and non-specific remittance code. Different Coders Being a large integrated health system has its advantages, and has its disadvantages. The health system that is the subject of this paper consists of 33 acute care hospitals, 700 physician clinics/outpatient facilities, and 11 specialty hospitals. The health system has a centralized coding team that codes for multiple locations in various states. They have specialized coders for service lines such as orthopedics, ear nose and throat, and OBGYN to name a few. Typically one coder does the professional side and another does the facility. There are occurrences where what the coders code is different for the same patient and procedure. An example would be the professional side coded but the hospital coded for the same procedure. This is a self-inflicted wound for the health system and has been the cause of several denials. Non-integrated Surgeons While the health system has its integrated doctors, it has aligned physicians who operate at their facilities as well. The integrated physicians are actually employed by the health system. With employed physicians it is easier to engage them when problems like claim denials occur. The non-integrated physicians have operating room privileges and choose to bring their cases to the hospital but are not employed by the health system. This presents a challenge because the physician s office is obtaining the prior authorization for both the physician and the facility when a procedure is being scheduled. The non-integrated physician offices are not part of the health system procedures and they are not standardized among themselves. Authorizations are handled differently for each office. For example, some offices fax, others , and some call to request their authorization to the precertification coworkers who then enter it into the EMR. Without having these practices integrated into the health system, the health system has almost no control over them or any way to verify if the codes being authorized are what were being billed. Urgent or emergent

10 PRIOR AUTHORIZATION DENIAL CHALLENGES 10 If a case is denied authorization by the payer, it is the surgeon s responsibility to cancel the case. Using sinus surgery as an example, an insurance company could deny authorization based on lack of medical necessity. Medical necessity is a healthcare service or supply needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine ( Medicare Information, 2017 ) All payers have criteria that must be met in order to deem a procedure as medically necessary. However, if the physician felt that it is in the patient s best interest to have the sinus surgery regardless of the insurance company s decision, the surgery often is still performed. In these cases it is the physician indicating that the surgery is urgent enough to bypass the insurance company s decision and proceed with the surgery. The challenge for a practice manager is that they are not in a position to argue the medical decision-making of the physician. This is also challenging because it presents the question of financial viability versus what is in the best interest of the patient. That again, is ultimately decided by the surgeon. The emergent issue arises with certain payers that require referrals in conjunction with an authorization, similar to the Medicaid requirement discussed previously. An example would be a patient coming through the emergency room (ER) for an appendectomy overnight or on the weekend. An appendectomy is the removal of a patient s appendix. Certain payers will still require that a referral be in place from that patient s primary care provider despite the patient entering through the ER. The challenge for the health system is ensuring the patient s clinic is notified that the surgery occurred so a referral can be obtained in a timely manner. The next section of this paper will discuss the countermeasures taken by the health system to reduce the numbers of claim denials for this reason. Countermeasures Prior to becoming involved in the prior authorization denials project there had been work done to try to address the issue with the authorizations not matching what was being billed. The health system s information technology team had developed a function within the electronic

11 PRIOR AUTHORIZATION DENIAL CHALLENGES 11 medical record (EMR) to try and capture the change in a procedure if it were different than what was originally scheduled and authorized. This function generated a report in the EMR that indicated a procedure change. In addition, the function was capable of flagging surgeries that had been added to the schedule the day of surgery. Typically, cases that are added on at the last minute have not been processed for prior authorization. This would seem to be the answer to the root of the problem; of procedures changing and causing the CPT code to change. If the change was detected then the health system could change the authorization before the claim was sent out. The practice manager and financial counselor in each office were responsible for checking the report daily and attempting to retro authorize if the payer permitted. The shortcoming of the report was that it had no correlation with a CPT code changing. The report was triggered from a nurse circulator entering into the EMR that there was a change in the planned procedure but the nurse circulator did not change the CPT code that was going to be billed. Therefore, it would still require an entry level staff member to attempt to provide the correct code on the retro authorization. Quickly, the practice managers realized the shortcomings of this function. The report derived from the function was only as good as the end user entering the data. Therefore, unless there was a significant change in the surgery being performed, no change was entered. This did not address the complexities of the troubles the health system was having with changes in surgery. Subsequently, this reporting function was not the fix the health system had hoped it would be. Focus Groups When the project team was organized, one of the first suggestions made was that this massive, complex issue be split into two focus areas with separate teams dedicated to each area. Only the integrated clinics and practices were included in the first phase but ultimately all practices would be part of this study if it proved to have positive outcomes. The team knew the shortcomings of the reporting function in the EMR, but it could still be beneficial. There was one team designated

12 PRIOR AUTHORIZATION DENIAL CHALLENGES 12 to focus in on that piece and work with the technology team and coding team to fine tune the function. However, the major hurdle facing this team would be that the EMR was incapable of capturing a change in CPT code due to the coding having to be done after the surgery was complete. The reporting function in the EMR began being solely used for checking if cases were added on and perhaps did not get authorized. The inability for the procedure changing in the OR to trigger the report that there was a change in CPT code still left challenges for the health system. The biggest shortfall was that were was nothing indicating what new CPT needed to be authorized. The second team was focused on developing standard workflows for all integrated clinics for obtaining prior authorizations. There were major opportunities in this process with the lack of coders in the integrated physician offices. Some of the procedural changes made were if the financial counselor authorizing a procedure or the requesting physician was not 100% sure on the code to be authorized to seek guidance from the coding team that services the entire system. An example would be if a physician was doing a surgery that was complex or not done frequently, the financial counselor would seek guidance from a coder on the coding team on which code they thought should be coded. Another major correction was if a surgery was not urgent or emergent and did not have an authorization, the managers were asked to have the conversation with the physicians and explain the financial impact of a denial. The standardizing of work was a big step in tackling this issue Coder in the Operating Room (OR) One of the alternatives considered after learning the weaknesses in the function of the EMR was adding a coder to the operating room to identify the new CPT code when a procedure had changed. In theory, this would be a good fix because the health system s major challenge had been identifying which CPT codes should be billed in the event of a change. The team put together a business case and justification for this position to be in the operating room. Financially

13 PRIOR AUTHORIZATION DENIAL CHALLENGES 13 the idea made sense, as well, because of the potential prevention of a denial that had such a large financial impact. Subsequently, the position should pay for itself. While the idea of having a coder in the OR seemed to be the perfect fix it had shortcomings as well. The field of coding has evolved to more of a specialized practice. Therefore, having a generic coder in the operating room was not going to necessarily be the answer. The other major issue with this idea is that a surgery cannot be coded without an operative report. An operative report is not completed until post-surgery, and it is what provides all the details from which a coder extracts information about the surgery and determines what CPT code should be billed. The idea of a coder in the OR at face value seemed to be a good idea, but after further evaluation of the idea it was decided to not be a viable solution. Coders in the Clinic The health system had decided years ago to have a centralized coding structure. All coders are remote, centrally located and able to code across the health system for their specific areas not exclusively for each community. This structure along with the EMR system allows them to cover more communities without having to be present in one location. The downside to this structure is that the coding and billing is done outside of the clinic and hospital. The idea was presented to bring some form of coding back to the health system integrated clinics. The thought of having coders in the clinics presented the opportunity to be more accurate while authorizing surgeries. This idea was short-lived primarily because of the overall success of the current structure of having a centralized coding team covering multiple communities. While having coders in the clinic would have assisted in the challenge with authorizations, it would not have been a wise use of resources. Holding Claims Over time the project team had been able to identify which payers the health system was having the biggest challenge with on their prior authorization rules. One rule that seemed to be consistent with those payers was that a clinic or hospital could amend the authorization so long as

14 PRIOR AUTHORIZATION DENIAL CHALLENGES 14 the claim had not been submitted. Once these were identified an idea was presented of holding claims to those payers until it was verified that the CPT code being billed matched what had been authorized. There were obvious advantages to doing this and it would prevent many prior authorization denials from being generated. However, if the system decided to hold all claims for a few payers that would drastically effect their days in accounts receivable. Days in accounts receivable (AR) is a metric used by both clinics and hospitals to determine how quickly they are receiving reimbursement on claims billed. The denials were decreasing the revenue being generated but holding all claims would slow down a larger portion of revenue from being generated. That concept is what ultimately eliminated this plan from being a feasible solution to the denial problem. Coders doing charge entry and coding The current process in the health system while working through this initiative was a coder coding the procedure, and then sending it through a work queue in the EMR to the billing team for charge entry. The Director of Coding had been working in another community on a pilot that called for the coder to do the coding and charge entry. This process offered an opportunity for a solution to the prior authorization challenges. There was one caveat to this being the solution-- was there a way for the coder to check the authorization? The answer was yes, there was a way for the coder to determine what was being authorized versus what the coder was billing. The group agreed that this could be the fix that would prevent the majority of prior authorization denials. The next step was implementation of this process into the integrated clinics. This approach appeared to be the way to decrease the authorization denials, but implementation had its challenges. The coder doing both the coding and charge entry was the piece that had to happen to ensure everything was matching before it was sent out. However, the coder was not the one that obtained the authorization, nor was it expected of them to do so. Therefore, there had to be a workflow developed around this process. Partnering with the

15 PRIOR AUTHORIZATION DENIAL CHALLENGES 15 information technology team, there was a program created within the EMR to identify when there was not a matching authorization to what was being billed. The coder would send a message to the financial counselor in the clinic to then call the payer and amend the authorization with the payer before the claim was sent. The other challenge is that this was a big change in the workflow for these coders. The coders were accustomed to coding and then sending the coded surgeries to the billing department. Now, it was required of them to do an extra step. In a large system this was not a switch that could be flipped in a short period of time. Therefore, the director of coding and two practice managers decided to begin the process as a pilot in their clinics. If this process were to be successful, there would be an incremental timeline of implementation for the rest of the surgical specialty clinics over the next several months. This is what the health system is currently doing as the solution for the prior authorization denial challenges. The implementation of the coders doing both CPT coding and charge entry, and verifying that they match, took place in December The two selected clinics were General Surgery and Ear, Nose and Throat Clinics. As of July 1, 2017, those two clinics have yet to receive a denial for lack of prior authorization during that time frame. The graph below is a depiction of the impact this project, starting with focus groups, began to have on the community with the integrated providers. Beginning in June 2016 through November 2016 there was a significant decline in prior authorization denials.

16 PRIOR AUTHORIZATION DENIAL CHALLENGES 16 $40,000 Outpatient Surgery Denials CY16 INTEGRATED ONLY $35,000 $36,061 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $7,208 $0 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 With the implementation of the proposed solution in all clinics this trend should continue. It is important to note that there is still a considerable amount of work for the health system to complete. This solution has been fully implemented in one of the four communities. It is encouraging to see minor successes with integrated providers, but there is still a broken process with the non-integrated providers that has to be addressed. The idea will be to partner with those offices in the same way the integrated offices were to ensure the billed CPT codes match the authorized CPT codes. The hospital coders that code the integrated physicians are the same coders that handle the non-integrated physicians offices. However, that process is still in the planning phase with the hope of beginning implementation in December Long-Term Sustainability In order for the health system to keep seeing improvements it must continue to monitor the success of this current process and begin to address the issues with the non-integrated providers. The health system is very large and for this solution to continue to be impactful it will need to be standardized across all communities. For any practice or health system, the only real

17 PRIOR AUTHORIZATION DENIAL CHALLENGES 17 way to ensure that prior authorization denials will be avoided is to be sure the claim is correct before it leaves the hospital or clinic. For smaller practices this may be a simpler process because most of the staff will be in one location. For large integrated systems the lack of sound processes can cost the system a substantial amount of lost revenue. Another implication to consider when addressing this problem is that the system must react to what the payers are asking. The policies change and the prior authorization requirements change frequently and there has to be a tactful way to respond to these changes. While this solution has shown minor successes, in two years there could be different rules which make this current process irrelevant. Lastly, astute contracting with payers in the future will be vital to ensure there are avenues to protect hospitals, physicians and clinics. There has to be an effort to negotiate windows for retro authorization and other applicable ways to make this process easier. In its current state, the prior authorization process is asking the healthcare providers to be predictable in an unpredictable environment. Conclusion This focus paper provided the successes and failures in prevention of prior authorization denials through the trials and tribulations of an integrated health system. The process of having the coders do both charge entry and coding is still in the process of being implemented across the integrated specialty clinics. If it proves to be successful in the community as a whole, the next step will be to start implementing in the many other communities of the large health system. The solution that was outlined is that a conscious effort has to be made to ensure the CPT code being billed is exactly what was authorized prior to the claim being released. This has been standardized in all integrated surgical practices for the community. The next challenge is developing the process that prevents the non-integrated practice claim denials. The major hurdle to overcome in the non-integrated clinics is that the system does not control those clinics. While this concept may seem simple, it can be extremely challenging the larger the organization is and if it is decentralized in any form. For all healthcare facilities, decreasing denials from prior

18 PRIOR AUTHORIZATION DENIAL CHALLENGES 18 authorizations and standardizing a successful process for minimal denial impact will be vital in the costly healthcare environment for the coming years.

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