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Try these techniques to help reduce the time it takes to receive pre-authorization and process appeals.

Fax the pre-authorization whenever you can

Place a statement on your fax coversheet that confirmation is automatically generated when transmission is successfully completed. It is my understanding that the clock starts ticking then. If you use this technique, please ensure that you have the correct fax numbers directly to the department that is designated to provide authorizations. In most states, a health plan has a limited amount to time to respond to a call for a pre-authorization. This time limit should be stated in the contract.

Make sure you have the correct fax number to circumvent delays

Be careful when using this method that you have the correct fax numbers. Verify the numbers before using them. If a plan gives you incorrect information, you could be directing your faxes to the wrong in-house office and delaying the initial processing by at least 7 days. Document your testing before sending the paperwork, both for HIPAA compliance as well as to circumvent problems down the road.

Whenever possible, get a physician involved to address any denial issues

If a plan delays the appeal and misses a deadline, call them and advise that since they failed to respond in a timely fashion to the appeal, you will go forward with treatment or surgery because they failed to follow their own deadline. This may raise the ire of the plan, when you advise customer service that you plan to go forward with the surgery since they have approved by default. These calls get pretty testy, so get a medical director name/phone number and have the attending physician get involved when indicated. Also, have a witness sit in on the call and document what transpired. Don’t be surprised when the calls get quite heated.

Open an appeal on a claim the same day that you receive notification of a denial. If the plan claims they sent notification, require them to prove that they followed the procedure stated in the notice section, and ask for verification that they sent the mail. If the staff member on the telephone states that they do not have to verify that they sent the denial, you will have your contract to argue back on this.

Appealing denied claims

Mail all claims by United States Postal Service-Priority Mail, with delivery confirmation. This may y costs around $5, but the envelope contains several thousand dollars in transactions/appeals. You can easily verify delivery online and print the confirmation that the mail was delivered to them. The clock starts ticking at that point. The plans know will figure out in short order that you know when the deadline is reached.

Record all discussions

Most health plans record all calls to document the contents of all discussions. You can easily do this as well. Several inexpensive recorders are available nationally at office supply stores and electronic stores such as Radio Shack or Frye’s Electronics. When they advise you that the call is recorded, advise them that you are doing it as well. Document the tape number, date and time right on the call and then record it in your notes. You might win more arguments if you can prove when you sent something or discussed some issue that has been denied. If this becomes a recurring problem, include mention of it at re-negotiation and ask for improvement or dditional payment to cover the costs of this activity since you can cost analyze the activity and track that cost specifically to that plan.

Use a tickler file and age your appeals the same way you age your revenue.

If your software allows you to have a running tickler file, use it! Set deadlines for follow up or completion and monitor all deadlines daily. Not only can you monitor appeals and pre-authorizations on a dashboard, you can also monitor how effective your staff is on follow up of these deadlines.

Dealing with paper claims.

Whenever possible, file claims electronically. The paper claims should be sent one to two claims per envelope. If someone is getting to go on a break or leave for the day and your envelope containing a large number of claims is next, it may get moved to the bottom of the stack so as not to create overtime. In situations where you send many paper claims to a single plan, arrange for a specific contact and send the envelope directly to your contact, including a cover sheet listing each claim and amount. Verify and notarize the batch and then send the envelope USPS Priority Mail with delivery confirmation. You will often see payment within one to two check runs, often within 28 days.

About the Author:

Maria K Todd, MHA, PhD is known around the world for her expertise and generosity in sharing ideas, techniques and practical tools with her colleagues in the industry. She is a leading health care industry consultant and described by clients and peers as a visionary and thought leader. Statistically, she is the leading trainer in managed care contracting worldwide.  Since 1989, she has lectured professionally through colleges, universities, seminar companies, publishers and non-profit professional associations as well as on-site private training classes for hospitals, medical groups, offshore revenue cycle business process organizations and pharmaceutical and medical device manufacturers. In total she has delivered more than 2600 managed care training classes and seminars to over 53,000 attendees and participants.  Every month the number grows higher and higher!

Conflict Disclosure: The author is a professional consultant and derives a substantial percentage of her income reviewing managed care agreements and advising hospitals, physicians and others on matters regarding managed care and contracted reimbursement. The author previously worked for a Health Plan in provider relations as a contract negotiator. The author has no other conflicts to declare. This disclosure accurate as of November 5, 2008.

Notice: Please remember that the opinions, and information contained in this document is that of the individual author.  These materials (1) do not constitute legal advice; (2) do not form the basis for the creation of any relationship; and (3) should not be relied upon without seeking specific legal advice with respect to the particular facts and current state of the law applicable to any situation requiring legal advice. These materials may only be reproduced with the prior written consent of Maria Todd.  These materials are provided with the understanding that the author is not rendering legal, accounting, or other professional advice or opinions on specific facts or matters, and, accordingly, such entities assume no liability whatsoever in connection with their use.

You can learn more about managed care contracting in Maria's latest book,The Managed Care Contracting Handbook, 2nd Edition (2009)

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