I usually get along with everybody, but since I’ve been on the insurance side, I’ve run into health professionals who act like I have horns and a tail.
A major health system racked up a ton of denials because providers failed to get pre-authorization for tests and procedures. When they appealed, they got denied again; they sent CPT codes and test results but not the clinical information required to establish medical necessity. I offered to meet with the responsible parties to provide the information they needed to avoid denials, AND GET PAID.
I was just trying to help, but no good deed goes unpunished. I couldn’t get to a medical director. As soon as I said I represented an insurance company, receptionists shunted me to a clerical person in the Claims Department. By going up the chain of command in Claims, I was able to get to a director who agreed to meet with me, but this lady acted like I was wasting her time. She sailed in and said she wasn’t interested in all denials, just the preauths and since they didn’t have a lot of members with this particular insurance company, my information wasn’t really important. Seriously?
I had already shown her staff how to search the website and find the list of tests and procedures that needed preauthorization, so I said, “if your request comes in without the necessary clinical information, you’ll get denials anyway.” When she admitted that the company I worked for was not their only source of denials, I said, “This information will decrease your denial rate for all payors.” That still didn’t get through. She kept insisting that she didn’t need to hear my presentation until I went North Philadelphia on her. “Listen, let me tell you what your docs need to do, and I’ll get out of your hair.”
Another time, a doctor requested authorization for a hip procedure, but the notes he submitted described findings in the spine. When I called for information, this guy kept trying to tell me what I would have seen in the documentation if I had looked. North Philly rose again. “Look, if I’d seen it in the documentation, I wouldn’t have called you. Just tell me what’s wrong with this lady’s hip so I can get you paid.”
When docs send authorization requests to an insurance company, understand that a fellow physician (the medical director) makes the final decision. Use the same colleagueship and communication standards you use when you sign out to your partner. You’re talking to me, not to the insurance company. Just tell me what’s going on and why you’ve decided on this care plan. I’m not questioning your judgment; I’m asking for stronger documentation. As a clinician, I can usually figure out why you decide to do a specific procedure, but I can’t change the documentation you send.
I need the “A” portion of the SOAP note (Subjective-What the patient tells you. Objective, what you observe, or find on evaluation. Assessment- So what? What does this mean? What could this be? Plan- This is what I’ve decided to do to find out, or make it better.)
Your note needs to document that this is the next logical step given the information you have and the treatments you’ve tried in the past. Why would simpler or less costly approaches be inappropriate at this point? What impact will the procedure or test results will have on the patient’s care plan? Will it clarify care options? Decrease pain? Improve other symptoms? Improve function?
I know that clerical personnel, not clinicians are directly responsible for the authorization process, but as it is with computers, Garbage IN, Garbage OUT. Find a way to design your forms or EHRs with a place to document the clinical decision-making, so the clerical people can find it.
We’re on the same side, people. Can we lose the attitude and just get the job done?
Dr. Woodson is a geriatrician and family caregiver who specializes in eldercare strategies to help caregivers, communities, and corporations serve seniors successfully. To schedule a presentation, private family or corporate consultation, contact her at www.drcherylwoodson.com The second edition of her popular resource, TO SURVIVE CAREGIVING:A Daughter’s Experience, A Doctor’s Advice and a new book, The Doctor is IN: Answering Your Questions about How to Survive Caregiving are coming soon.