How Small Hospitals Can Prevent Prior Authorization Breakdowns

In today's presentation, we are going be talking about prior authorization, which can put a lot of pressure on smaller hospital systems.

One missed requirement, unclear handoffs or documentation gaps gaps can turn into delayed care, extra re rework, and revenue your team is working hard to protect. So today, our speaker, Lianta Williams, she'll be sharing how to make prior authorization easier to manage, measure, and improve without adding more confusion for already busy teams. Lee is our director of education. She brings over twenty years of experience across both outpatient and inpatient settings.

Her background spans coding, CDI, auditing, physician training, practice management, and compliance. She's an independent health care consultant and also provided coding oversight for organizations, including the CDC, the US Consumer Product Safety Commission, and industrial economics. Lee knows this topic from every angle, the clinical side, the compliance side, and the day to day reality of making it work in a busy hospital. So with that, I'm gonna hand it over to you, Lee.

All right. Thanks again, and hello to everyone on. Welcome. Welcome. Thank you for joining us today, and we're going to go ahead and start with our presentation.

When you think about prior authorization challenges, I think many of us often picture large health systems with dedicated authorization departments, And the reality is very different for many of the community and small rural hospitals that some of us work for.

Smaller organizations are expected to manage the same increasingly complex payer requirements with fewer staff. And I think for many of us, probably most of us, we're all experiencing that squeeze when it comes to to staffing.

Smaller organizations are expected to manage, again, the same increasingly complex requirements. They have fewer staff. They have fewer specialists. And they're looking to do this with less redundancy.

So today we'll look at where prior authorization processes typically break down, why those breakdowns occur, and look at some of the practical strategies that small hospitals can implement without adding significant resources. So the focus of this presentation is really going to be looking at processes and how we need to evaluate our current processes and where tweaks or enhancements can be made to improve those processes.

Prior authorization requirements, you guys know, continue to expand while staffing challenges remain.

Over the last few years, there has been heavy concentration on prior authorization. CMS has dedicated to reducing the burden caused by prior auth. We've seen other, payers like UnitedHealthcare also commit to this.

But throughout a year, you will also see those payers remove perhaps certain procedures, services, products from their prior authorization list, but then they'll also add certain procedures and services. Right? Something that probably did not have to receive prior auth before now has to. So just really staying on top of those changes, those additions, those removals are important as well to make sure we're on top of our prior auth. Many small hospitals have registration staff.

Some could have coders, for some it's nurses or case managers, or perhaps even people in revenue cycle, all sharing pieces of the authorization process.

That means success depends less on having more people and more on having better coordination, and that is really key. So today's discussion is about recognizing where communication gaps occur and building processes that helps everyone succeed. So it's really when you have a group of people working together to achieve this goal, making sure that everyone is doing their piece of the puzzle. And that really starts with the front desk, right? Making sure we have the right insurance information.

If there is a secondary payer, we also have this. Many organizations, they focus on the primary payer and making sure they have authorization for the primary and maybe not so much on the secondary end. But it's important to get your prior auth from both primary and secondary where you can just in case primary doesn't pay or doesn't authorize. Sometimes it's contingent for the secondary, but sometimes it's not. So when we're dealing at revenue cycle, we try to make things as easy as possible.

And that sometimes because, again, we're challenged by denials, we're challenged by staffing. So for many organizations, they may say, Well, if Medicare says this, this is the rule we're going to apply across the board. And that may work in some instances, but in other instances, you may find that it may not work as well as you think because you're missing out. So just really thinking about all those pieces and how it's gonna benefit the providers, the organization is going to be important.

So before we get into the fixes, let's ground the problem a little bit in actual numbers because the scale of this is easy to underestimate. In twenty twenty four alone, Medicare Advantage plans made about fifty three million prior authorization determinations, and virtually all their enrollees, ninety nine percent, need authorization for some services.

It's no surprise that medical practices rank prior authorization as their single biggest administrative burden. For a small hospital, that national tidal wave shows up as a daily flood on a handful of desks.

And in my past experience, some of this ended on my desk. Medicare, I would say, was probably for us, in my region, one of the easiest because they didn't require prior auth for many of the services for the organization that I worked for. But when we looked at the MCOs, the advantage plans, the commercial plans, that's where we saw the heaviest request for prior auth.

The issue with Medicare, some of you may experience is they may not have required the prior auth on the front end, but then we got a denial on the back end after the service was provided. So being able to balance that again and dig into the root cause and what needs to happen for the next patient encounter was important. So keep these numbers in mind. Everything we cover today is about managing that volume without burning out the few people who handle it. Because, again, you're looking at a smaller team that's typically supporting prior auth, and it can become very stressful and difficult to manage if we're not evaluating our processes effectively.

Now the denials, of those millions of requests, about seven point seven percent were denied or partially denied in twenty twenty four, and that's roughly four million care decisions.

Now here's the part that should stick with you. When patients or providers appealed, more than eighty percent of those denials were overturned, and yet only about eleven point five percent were ever appealed. And I know you guys have heard this from presenters, whether it's directly from AAPC or from another vendor. We know that usually providers are gonna have a good success rate on appeals.

The issue is that it takes time and it takes resources to appeal, so many times it's just not done. Now when we look at those two numbers, the seven point seven and the eighty point seven, looking at those numbers together, the vast majority of denials that gets challenged are reversed, but, again, almost nobody challenges them. Now that tells us two things. Many initial denials don't hold up, and there's real ground to recover if we make appeals routine instead of exceptional.

Now this is on the back end. This is after you have obtained your prior auth or tried to obtain. Perhaps you missed the prior auth, and the service was rendered. It was denied afterwards, then you get a denial.

Being able to appeal a authorization denial, that system or that process is a little different. Right? And for most of us, if there is a payer where perhaps it's a drug, for example, and the provider is ordering a certain drug as treatment for whatever condition this patient has, We know that payers have preferred drugs. So the provider may say, I want to order this particular drug for this patient.

And when the request is submitted, the payer will come back and say, well, our preferred drugs, we have two options for you, option a or option b. So in most cases, the provider is going to default to the payer's drug options. If they feel it's safe for the patient, they're going to get the same treatment efficacy, they're going to default to the payer's preferred drug to make sure that it's covered.

The the patient isn't gonna have any out of pocket expense going forward. However, there are some scenarios where the provider's original order for a certain service, a certain drug product, whatever it is, if the payer says no and here are your options, the provider has the option to do a couple of things to try to sway the payer.

One of those things is to write a letter of medical necessity. Right? They can write a letter of medical necessity to the payer explaining why their recommendation for a particular service or a particular drug, again, a product, is going yield the best benefit for the patient based on medical evidence. And it's important that they include medical evidence in their letters.

Another option that providers have is to do a peer to peer. Sometimes the payer will say, okay. Well, your provider can get on with one of our specialists on the payer side, whether it's a clinician, and they can have a conversation about, again, why their recommendation is the one that the payer should approve. Some cases it works, some cases it doesn't.

And again, this is time. Right? Now you're looking into the clinician's time, the clinician's time to write that letter, the clinician's time to get on the phone to do that peer to peer, but it is successful in some cases. If that's not something that providers at your hospital or your organization is doing.

It's definitely something that they may want to look into.

Numbers can feel abstract, so let's connect them to people.

One in five privately insured adults had care their own doctor recommended denied in the past year.

Among patients hit by a prior authorization denial, forty one percent reported that their care was delayed. And that's typically what happens. Right? If you don't get something approved, it is going to delay care for a patient, and that is something we want to avoid. That delay is the patient waiting, the patient worrying, and sometimes getting sicker while paperwork gets sorted out. And, of course, patients don't understand this whole process, and all they know is they have insurance and why something isn't covered, why something is excluded, especially in a scenario where they're hospitalized or they're seeking additional treatment post discharge, that is very difficult for a patient to comprehend.

This lands hardest, we know, on rural hospitals. Medicare Advantage enrollment has grown one hundred and twenty percent since twenty fourteen, and those plans carry far more authorization requirements than traditional Medicare, as I mentioned earlier. So smaller hospitals are absorbing more of this burden with the least amount of staff to handle it, and that is very concerning.

A prior authorization isn't just a box to check. This is very critical in your ecosystem, in your health system.

So if you are a decision maker at your organization and you're not putting emphasis into making sure that you have the right staff, people who have the expertise to work in that role. You're providing training. You're making sure as contracts get updated, that information is trickled down to those people and also your clinical staff so they understand what's going to be covered, what's not covered. These are things that you definitely want to start investing time in.

When one requirement or piece of documentation gets missed, it sets off a chain reaction that touches everything downstream.

And you guys know, for those of you who are on the line who may be coders, you understand the importance of documentation. We have the impact to the patient. So first, the patient. A misstep means their care gets delayed while we go back and forth on paperwork, like I mentioned earlier.

Because at the end of the day, that's what it is. That's someone waiting on a procedure or perhaps a medication because of a process gap, not a clinical one.

Second is staff. Every miss becomes rework, and it lands on people who are already stretched thin. In a small or rural hospital, there is no dedicated team to absorb that at times. So it pulls the same few people away from the next patient. And then third, of course, is revenue. This is money the team worked hard to earn and protect, and a single documentation gap can turn it into a denial.

For a lean system, that lost revenue is the difference between keeping services open and cutting them. All in all, one small miss is never really small. It costs patient care, it affects staff capacity, and it impacts revenue.

And this is why we're going to talk about some of the fixes that we can implement as soon as we identify or dig a little deeper into the breakdown. So now that we've seen what a single miss costs, we can look at where these misses actually happen.

Denials rarely come from one big failure. We have little nuggets that come together that's going to trigger that denial. So they come from a few points along the way, and I think I have four on this slide that we're going to go through.

And all of these impact your authorizations or put them at risk.

First is the ordering. This is a timing problem typically. The treatment gets ordered, scheduled, delivered before prior authorization staff has the runway to submit and work it. We're starting the clock behind, and everything after this is trying to catch up.

At an organization that I worked at, it wasn't hospital well, they were a hospital affiliated group, but it wasn't a rural system.

But often, the providers would order treatment very quickly. Let's say we had a patient who was discharged from a hospital, they're coming in to see the provider to start outpatient care. Naturally, the provider wants to see the patient as soon as possible, get care started. Absolutely nothing wrong with that. But we know that it does take time to submit an authorization request and get an answer from the payer. So allowing that efficient amount of time is important. Depending on the payer, depending on the the ask, the service, or the procedure or the product, that's gonna impact the timing or the turnaround time.

For some payers, you can get a response really quickly, within a couple of days, two to three days. Some payers, it may take five to seven days. Then we have some payers in my state, like Medicaid, it can sometimes take up to fifteen days before we get a response back.

So again, making sure that everyone who is involved in the process understands that this is a timing game.

And yes, clinicians want to see patients as soon as possible, but that also means they need to submit the request timely and that they have documentation in their record to support that auth request, Right? How many of you have submitted a request and clinicals are needed, notes are needed, and there is nothing in the medical record? The provider hasn't done the H and P. There isn't consult notes available if that's required. There isn't a discharge summary available if that's required. So timely documentation is important. It is needed in order to get some of these authorizations approved.

And then we wanna make sure the documentation does capture what the payer needs to approve. So pulling language directly from their policies is also key to making sure that you have that support that's going to help get that approval. Third is submission.

There sometimes isn't any clear owner for who submits. Again, if you have a prior auth team, you have dedicated people, to submit the auth, that's great.

Part of what happens here is if there isn't someone dedicated, the follow-up is lost. Something is submitted, but let's say the payer comes back and they want additional information. Who owns that? Who is responsible for going back to that clinician and saying, We need this piece of information or data in order to submit to the payer to support this request. So making sure we have a system in place that clearly identifies who is doing the submission, who's doing the follow-up, how is information being requested, how is it being received, what is the follow-up process, that is important as well. And then payer review. Even a clean request meets inconsistent interpretation across payers.

And we have no system to track how each one behaves. We should. You should do a a profile on your payers.

One of the things we do in revenue cycle, many organizations, is to create a profile on payers as far as how they pay. How often are they denying? What are they denying? What are those top ten diagnoses or those top ten procedures that often trigger a denial?

What do they hold for a prepayment review before they pay the claim? Think about what you do on that end from a finance perspective and how perhaps it can also be applicable here more on the front end, the prior auth perspective. Building a profile on your payers, knowing who approves what as far as their preferred list, knowing who often requests additional clinical so that way you can try to get ahead. There are some organizations where we are going to say, Go ahead and draft that letter of medical necessity now so that we're not waiting for a denial to try to appeal with that letter.

Let's go ahead and be proactive and get these things available, submitted, even if it's in draft form so we have them if needed.

These are all process gaps, not necessarily clinical gaps outside of the documentation piece. Right? And because they're process issues, processes can be fixed. So each four of these points maps directly to a solution on this slide.

This is our first fix, and it maps directly to the ordering breakdown we just saw. Again, the problem is typically timing. And I know in a hospital setting, things move quickly, may not have the time, the opportunity to do all of these things early on. And that's to be expected. That's how it typically functions in a hospital setting.

But you still want to make sure these things are done as soon as possible. So making sure once something is ordered, that triggers the process, and there is staff working on getting whatever authorization is needed for that particular service or whatever the treatment is, someone is working it, and someone is following up with that payer. Education is important when it comes to process change. Your providers aren't trying to create WeWork.

In most cases, they simply don't have visibility into what a given payer requires. Right? And as I stated earlier, it changes through the year. They may add things to their list that requires prior auth that previously did not.

So it is making sure that we communicate somehow to stakeholders what is approved, what is not approved.

Some practices or systems have a grid where the provider can check off, again, treatment based on the insurance coverage. So whatever it looks like for your organization from a communication perspective, again, just making sure people have the information at hand to make those informed decisions. And if the provider knows that this is a service, this is a procedure, this is a drug, that's not going to be covered, okay, what is my next step? What is my responsibility to make sure that the payer has the information they need to approve this?

So there needs to be a shared understanding. Clinical staff needs to know what the payers require, and typically this is great if they know before the order goes in. That's not asking clinicians to become authorization experts. That's just being able to recognize triggers, and that's something that you can do within your EMR. The second move is structural. Build a standard lead time into the ordering process or ordering workflow so prior authorization staff actually have time to rework.

When lead time is designed into the process, we stop starting every case behind.

So patient is admitted for a surgical procedure, and they're admitted for that procedure two weeks from now, we have time to start working that. If it's not an emergent situation, we typically have time to be able to submit the information to the payer in order to get that approval or get information to them to try to get an approval if it is denied initially.

Now, let's talk about what it costs when the workforce isn't fully trained for this type of work. These aren't performance problems with individual people. They are symptoms of a process that expects staff to learn a highly technical task on their own.

You see it in consistent payer interpretation from one staff member to the next. It's important that you have internal documentation, internal resources for teams, for the people who is who are doing the work, and that you are offering training. You're making sure that everyone is on the same page. You're making sure that the documentation that's needed by the staff is in the system. Everyone's documented in the same way, and there isn't any gaps.

What the payer requires, that type of information should be accessible within the tools and resources for your staff handling this particular type of work.

Underneath all of these is the same root cause, staff who learn the process by trial and error, right? How many of us are put into a position, and it's like, here you go, go ahead and do it, without proper training. Training is key.

In any facet, training is key. In a small hospital where a few people wear many hats, that gap gets very expensive very fast.

The takeaway for the room is that training isn't overhead. It's the cheapest really, it is the cheapest denial prevention tool that we have. Rather than going out and spending a ton of money on fancy tools or software, which, you know, nothing against that, whatever makes your organization more efficient, is great. But at the end of the day, this is still very much a people or a human function, and being able to train your staff and empower your staff to do the job is really where you are going to yield the best benefit. So again, I can't emphasize how important training really is, training and communication.

It's helpful to think of a denial as the final symptom and not the actual problem.

Most denials began days or weeks earlier. Remember, it's a process. It's nuggets. It just doesn't happen usually in one setting or one bulb.

You have things leading up to that denial, gaps, deficiencies. Perhaps documentation wasn't complete. Maybe the authorization expired. How many of us have encountered that?

We have an authorization for the next three weeks. We have the next three visits.

You have authorization for a certain dosage of drugs. It expired somewhere, and no one caught it. It wasn't flagged. The patient came in.

They had a service. Well, the authorization expired. How likely are you to get a retro authorization? That's very challenging in today's environment.

Many payers do not offer retro authorization. Right? So once it's gone, it's gone. It's denied.

That's the end. So we want to make sure that we're paying attention to these things.

We want to make sure there's ownership between people, between departments.

When organizations review denials, they should focus less, I usually say, on who made the mistake and more on where did our process fail.

That is what the focus should be. When you trace them back, most denials come down to one of three things: incomplete documentation, missed deadlines, or unclear ownership. Oh, I didn't know I had to do that, or I didn't know that was tasked to me, or I thought this person was handling that. So keep those three things in mind: incomplete documentation, missed deadlines, unclear ownership.

Because nearly everything we recommend next is aimed at really one of those three things.

Up to now, we've been dealing in numbers and process diagrams. So we're gonna take a minute here. We're gonna walk through a case study where we're gonna see where, there was a system failure or a process failure. So it's a busy Friday afternoon. In this case study, we have a sixty bed rural hospital, a patient with worsening back pain, and an outpatient MRI that was ordered right before the end of the week.

So nothing here is unusual. Okay? That's the point. This is a completely ordinary order, and I want everyone to picture their own facility as we walk through it. The order lands on the prior auth team.

There is virtually no lead time.

The clinical notes don't include anything around perhaps conservative treatment that the patient had in the past.

And naturally, this is something the payer is going to want to see.

Nobody clearly owns getting the submission out the door.

Notice that no single person did anything wrong here. It's, again, the process. Sometimes we get orders. A payer may get an order, and it's for, again, we're getting an MRI. The intent is because of this patient's worsening back pain, it's going to be worked up. We want to see what is the cause, if there's anything on radiology.

Your EMR system, sometimes the diagnosis code that goes over on the order is incorrect. And that is an issue. Right? The radiology, if it's going to an off-site team, they may go ahead and flag it.

They'll send it back to you. But in some cases, there are orders that go out, and it's not the correct diagnoses, or it's a list of diagnoses because the EMR just pulls all the diagnoses onto that order. We want to make sure we have a clean order, just like we have a clean claim. So we have the correct procedure listed, the correct CPT code, we have the correct diagnosis code or diagnoses codes that supports the order that's being written.

Then there is documentation of the need. If it is a payer that requires step therapy, patient may have to have failed A, B, and C before we can approve D. You want to make sure you give that information up front. Ultimately, this request is denied for insufficient documentation.

Care slips nine days and the staff burn hours on rework and appeal. The patient is in limbo, right, doing all of this, and they're still experiencing pain. Pain hasn't gone away. The prior op team has to delay requests in queue to handle what is now a stat request.

How about all those stat requests? Right? Stat requests, you have to drop everything. You're handling this stat request right away. Is it truly a stat request, or is it something that became a stat because the processes won't follow through effectively.

The fix is not in new technology or more staff here. It was three of the changes we covered, cross functional ownership so someone is clearly accountable, You have enough lead time, seventy two hours per se, to make sure that you have submitted to the the the payer and there is enough time for an approval to come back before the patient is shows up for the service. Small, practical, and doable in a small hospital or in a physician practice.

Of note, some payers require more than seventy two hours depending on payer, as I mentioned earlier, some five to seven days. It's really just going to depend on the payer. Unlike claim denials, a hundred percent of prior auth denials are avoidable.

Now it can be that something is totally excluded. That's a plan exclusion. There is nothing we can do about it. But oftentimes, it's it's timing, it's insufficient documentation, it's incorrect diagnosis codes, it's the fact that labs are required, lab values, I would say, for a particular service, and that wasn't included. So the reason why I say a hundred percent outside of those, exclusions and things like that is because oftentimes it's something that we did not provide or something that was not correct or the timing issue that triggers that denial. Building clearer workflows across teams are essential for success.

You want to assign cross functional ownership for each step. Something needs to go back to the provider, to the nursing staff, who is following up, what is that timeline for them to get that information back to the prior auth team. So someone needs to be able to visually see, monitor, track that that system or that progression so that nothing falls in the gap between departments.

Secondly, add prebilling checks.

Before a claim goes out the door, catching a missing element while we can still fix it is far cheaper than fighting a denial after the fact.

And then third, build denial prevention checkpoints into the process itself. Rather than bolting them on after a denial happens, the goal is to move from reacting to denials to designing them out. Okay? Again, many of this is avoidable, just like in a claim. Now you are gonna have payers that are gonna deny medical necessity, some other things where you disagree with that happens in revenue cycle. Again, when it comes to authorizations, I think there is more control in that space if we have the proper processes in place.

We're going to talk through documentation and some other things, again, as we stated, that impacts your approval rate for your auth request.

Start from the payer's own medical necessity criteria and write the note to answer them directly so the reviewer doesn't have to hunt for the information. You want to capture the conservative treatments already tried and failed. So you include your dates. You include treatment outcomes so that the payer sees, okay. We did all these things. It didn't work, and that's why we are ordering this particular service, this particular therapy, this particular drug, whatever it is. Make sure your diagnoses codes that you're using are specific enough to match their rules.

You want specificity is important. Just like on your claim, when it comes to your auth, that's also important.

Make it repeatable. You build a short checklist for your highest volume of procedures and put a second set of eyes on the packet before it goes out, not after the denial comes back. Again, it's trying to be as proactive as possible. Prevention here, again, is cheaper than having to spend time appealing on the back end.

Training, as I mentioned, is also very important because process only works if people know how to run it. People know what is expected of them. So the big shift is replacing trial and error learning with a real onboarding path. So nobody is left to figure out authorizations on their own. Cross train where you can. So if someone is on vacation or if someone resigns, nothing isn't lost.

Keep a living payer playbook, if you will, who requires what and how long it takes. So the knowledge lives in the system and not in one person's head. And across many practices, many organizations, we have that where Sue knows everything. Right?

You need to know something. Go ask Sue. Well, what if Sue isn't here anymore? What do you do then?

So we want to make sure that we have an operations manual, something tangible that your staff can refer can access and refer to.

Review denied cases together as teaching moments, not blame, and refresh training whenever the major payers change their rules, which they do often. Training isn't overhead. Remember, it's the cheapest denial prevention that you have.

Technology is the third thing. So we talked about training, documentation, technology. Use technology where you can to improve processes, automate as much as possible where you can to make life easier for your staff. And on this slide is just a checklist of some things you can do to leverage technology.

Tracking is also important. If we want these fixes to stick, you have to measure them. So here we're gonna look at some of the things that you wanna track. Some of the metrics to track include your prior auth denial rate, of course, how much lead time cases get before the deadline.

So what is your average turnaround time? When an order is submitted, how long does it take the team to get to the order, submit the order, receive a response? These are all areas where breakdown may occur. You don't really need a sophisticated system to start.

Most payers have electronic systems. You can pull reports in some cases. What also needs to happen is proper documentation in your EMR. So someone's capturing the date of the approval, the approval number, all the things that's needed in case there is a denial even after approval because we all know approval doesn't guarantee payment.

Right? So how do you roll this out without overwhelming the team? In phases. There's a lot of information on this slide.

You guys will get the slides, so I'm not going to read through this. But I wanted to leave you with, if you wanted to if you don't have that stability with your prior auth team, or maybe you don't really have a prior auth team and you want to build one, or you want to reinforce what you have, the next set of slides is really just some foundational things that you can do to get to that point. So this slide talks about the doing a road map, and it gives you, again, a breakdown by weeks, by months on what you wanna do to get to that point.

Your first ninety days is here. So day one to thirty, what that looks like, thirty one to sixty, so on and so forth. Again, not gonna spend a whole lot of time. You guys can look at this, if you need to once you get the slide. Again, our goal was to give you something that you can refer to.

Roles and responsibilities, that's important, making sure everyone understands what their role is, what their responsibility is in that process, and, again, making sure that we're communicating what's needed so every individual knows what is required of them. The clinicians know what to document for that payer criteria.

The folks who are doing the the authorization request or who are maybe part of the revenue cycle team, someone is tracking.

Looking also at your denials, your write offs when you do get a denial and that denial is based on prior auth or lack thereof, what is that financial impact to your organization?

So really looking holistically at the whole process is going to help you build a more stronger prior auth process.

So some key takeaways as we end, and we do want to leave a little time just in case we have some questions.

Again, prior auth delays are patient care delays, so leadership needs to understand that and really, again, invest the time into education, into training, into process improvement.

It's not just an administrative issue.

This is a real patient care issue. Clinical and revenue cycle teams need shared expectations, not separate processes.

Training is important to make sure that we're closing the gaps.

And then standardized workflows. What can we do to make work more efficient, more effective, and reduce any redundancies that we have in our processes?

So I hope the presentation today just helped inform you a little bit about some of the things that you need to pay attention to when it comes to process improvements within your organization, and again, some of the information within the presentation about implementation.

Hopefully, it'll be of value to you guys. So that's the end of the presentation.

And, Stephanie, I'm gonna check the chat.

I don't know if we have Yep. There's some questions here.

Someone just made a comment in the chat that it's always good to have a referral process guide to close the loop on every referral request.

Absolutely. Absolutely.

And then there are two open questions in the q and a module. Sandra asks, are the pre auth denial appeals percentages that overturn earlier earlier sorry. Earlier denials similar to commercial plans?

Need to do I need to repeat that?

Yeah. Repeat that for me, please.

Are the pre auth denial appeals percentages that overturn earlier denials similar to the commercial plans?

So that the percentages I showed earlier were, really focused on Medicare Medicare Advantage plans. It did not include commercial plans. Okay. So I don't have that particular data.

Okay. Great. And then who takes accountability, or rather who holds the financial costs of a missed authorization?

Should it be the patient or the hospital?

Typically, it's going be the hospital. That's going to boil down to your contract. Right? So if your contract states that if you did not get the prior authorization at all or if it wasn't approved, the patient is not responsible.

And generally, that is what a lot of the contracts say. So that is really going to be based on just what the language is within your contract. In many cases, you can't go back and balance bill the patient if your contract says that you are unable to do so, if a authorization was denied and you still proceeded with the the procedure. So that really is gonna be based on the contract.

Okay.

And then, okay. This question has came into the chat. How does the surprise bill work if this is it state by state?

So the surprise, if I'm thinking, if I'm understanding the question, there was a lot of regulatory work done about surprise billing and just making sure that patients are aware of the cost of care before it is rendered so that they're not surprised by your bill. So that's more on making sure that information regarding cost of services are on the hospital's website or portal is somewhere where the patient can access and download that information so they know what potentially the cost is of a service. Now, are some states that may go a little more into detail or require more than what the federal government has required, but I'm not sure. That is going to be based on that particular state, so you'd have to do some research on your state. And if there were some additional criteria or requirements by that particular state. But surprise billing is really being as transparent as possible with the cost of services before a patient gets those services.

Okay. And when a provider gets a prior auth for a surgery, then when they get in there and things have to change, is there a way around this?

It's really documentation. It's it's documentation if there is a you know, there's extenuating certs circumstances that and it does happen. Right? Patient's blood pressure drops dramatically, so additional resources is needed, whether that's nursing support, that's drugs, whatever it is.

It's really making sure that that's well documented, the care is evidence based, and if it is denied, getting with the payer, doing the work. So whether that's that letter of medical necessity, whether that's that appeal, whether it's the peer to peer, it's making sure that you have the clinician who understands that that is additional steps they must take in order to overturn that denial. If the documentation supports the care that was rendered, in many cases, you will be okay. Now, you know, it's not a guarantee of payment by any means by a payer.

Ultimately, it's their decision. But in my experience, if the documentation supports and the provider is willing to do the extra work to show how it was medically needed or necessary, that is the key.

Thank you, Leah. Okay. This question is a little specific.

Any tips on explaining to a resistant managing provider the need to train or trigger the providers to look for authorization details or requirements? Yes. Simply stating the financial risk does not do it. They are licensed providers with limited Right. And training.

I mean, I try to make it relate to the patient as much as possible.

They are focused on patient care, which they should, but all of this equals patient care. So what happens if you don't have the information, in the chart?

How does that impact that prior auth? How does that impact the denial? How does that impact the patient? The patient being able to get the treatment, get the care that they need.

And then outside of that organization, right, if the patient is referred somewhere, how is that referring provider going to be able to handle their referral if the if the ordering provider didn't do what they were supposed to do? So I know sometimes it's difficult having these conversations with providers, especially when we're focused on finance. It's really understanding or getting them to understand really how it impacts the overall care of the patient and their ratings as well, you know, how the the provider their profile. So you can try explaining it to them in that way, focusing on those other areas outside of finances.

Outside of that, you know, we're here. Sometimes you can tell a provider something five thing in five different ways, and sometimes it's hearing from someone else, like someone from AAPC that says the same exact thing that's able to back you up. Sometimes that does the the trick in my experience. So if there is a need to reach out to us so that we can provide some of the information that maybe you have already been relaying or communicating to your provider, that's something that we're here to do as well because I do know that that often happens.

Thanks, Lee. Okay. Here's one more question. Why are the Medicare Advantage plans so different to coverage as compared to basic Medicare? Yeah. Yep. I thought I had read Yeah.

You know, it's yeah. I think initially I see that question, Carl. Yeah. And, initially, I think that was the idea.

Right? It was the advantage plans was a option for patients, but it was gonna be just like Medicare, plus you had some additional services or benefits. But at the end of the day, those Advantage Plans, they're able to write their own policy, and we are seeing that just because Medicare covers something, traditional Medicare, I would say, doesn't necessarily mean that the Advantage Plan is going to. I think that's how the concept started off.

That's definitely not where we are today.

And, unfortunately, I don't have an answer for you, but I'm seeing the same thing that you're seeing. So I definitely understand the frustration there.

Yeah.

Alright. That, I think, that's all of our questions, Lee. Thank you so much. Thank you.

We'll go ahead and wrap up here.

There will be two quick questions that come up at the end of, this webinar right after the session ends.

Lee has talked a lot about training, and that is where AAPC can come come in. If you are looking for ongoing training access for your coding and revenue cycle staff, we have our corporate membership, which is really valuable, offering webinars and workshops and upskilling opportunities through certifications. So that'll be the first question is if you're interested in learning more about that. Otherwise, we can also offer some customized training, especially around prior authorization. Lee is the expert in this area and will be one of the subject matter experts that you could potentially work with. We would just build that training around your team's specific workflow gaps.

So if you're interested in your either of those, please let us know. Just indicate that on our closing survey.

And with that, this will conclude our webinar. Thank you so much, Lee, for being here and for just your expertise in this area. We are so grateful for it, and I hope you guys all have a great rest of your Tuesday.

Absolutely. Thank you. Enjoy the rest of your day, guys.

Thank you.