Transcript Referral and Authorization Process in the Managed Care Environment By:

Referral and Authorization
Process in the Managed Care
Environment
By:
Debbie Jankowski
and
Joan Horen
Definition of Managed Care
A system of health care delivery that tries to manage the cost of
health care, the quality of health care, and the access to that care.
Common denominators include a panel of contracted providers that
is less than the entire universe of available providers, some type of
limitations on benefits to subscribers who use noncontracted
providers (unless authorized to do so), and some type of
authorization system. Managed health care is actually a spectrum
of systems, ranging from so-called managed indemnity through
PPOs, POS plans, open panel HMOs, and closed panel HMOs.
In 1973, fewer than one in every 25 privately insured Americans
were enrolled in a managed care plan, now two out of every three
privately insured Americans are in such a plan.
Reasons for an Authorization
System
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Case review for medical necessity by the medical
management function of the plan.
Direct care to the most appropriate setting.
(Inpatient vs. Outpatient or in the provider’s office)
Provide timely information to the concurrent review
utilization system and the case management system.
Assist in the finance estimate of the accruals for
medical expenditures each month.
Authorization System
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Has to define what services require
authorization and what do not.
Determine who has the authority to
authorize services for members:
PCPs
 Plan’s Medical Director
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The tighter the authorization process the
stronger the utilization management by
the payer/plan.
Authorization Types
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Prospective
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Concurrent
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Issued before ay service is rendered
Allows for timely data collection and the
ability to impact the outcome
Retrospective
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Issued after services are rendered
“Emergency Situations”
Authorization Types (cont.)
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Pended (for review)
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Determine the status of an authorization:
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Medical necessity
Eligibility
Administrative review
Denial
Subauthorizations
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Common with hospital based services
(Radiology, Pathology, Anesthesia)
Common Authorization Data Elements
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Member’s name
Member’s birth date
Member’s plan identification number
Eligibility status
PCP
Referral provider’s name and specialty
Outpatient data elements
 Referral or service date
 Diagnosis (ICD-9-CM)
 Number of visits authorized
 Specific procedures authorized (CPT-4)
Common Authorization Data Elements (cont)
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Inpatient data elements
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Subauthorizations
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Name of institution
Admitting physician
Admission or service date
Diagnosis (ICD-9-CM)
Discharge date
Hospital based providers
Other specialists
Other procedures/studies
Free text to be submitted to the claims dept.
Methods of Communication
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Paper-Based System
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Telephone-Based System
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Pre-printed paper forms through the mail
Phone tag, busy signals, waiting on hold
Busy fax machines
Electronic System
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Built in edits on-line
Claims submission most common
Authorization & Eligibility information available
Dedicated lines connected
Problems with Authorization Systems
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Lack of standardization of required
information and format between the
insurance plans
Coordination among the players of the
paperwork
Ongoing changes
Administrative costs
Declining reimbursement
IT “Solutions”
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Swiping Card
Telephone
Entering Number on Keypads
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Limited Functionality
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Application Service Providers
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Integration of eligibility, authorization, referrals
Physician Offices and MCOs
Cost Savings
 Medical Mutual of Ohio – reduce 10-12 FTEs = $600,000.
Time Savings
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Authorizations from 30 minutes to 10 minutes
Reduction in errors
Improved Patient Satisfaction
One-Stop-Shopping
Diffuse Costs
Regulatory Issues
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HIPAA – Health Insurance and
Accountability Act
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Adminitrative Simplification
Standardization of Claims/Referral data
Format modified on every 12 Months
Web ROAR
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ROAR – Referral or Authorization
Request
Keystone
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Ranked 8th in Nation’s 25 Largest Individual
HMO Plans
1,151,224 members (1998)
Web ROAR
Web ROAR Functionality
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Submit referral and authorization
requests
Verify patient membership
Search for specialists, providers,
hospitals, or other facilities
List historical referrals/authorizations for
patients or practice
Track utilization patterns for practice
Web ROAR Main Menu
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Request for Services
View Messages
Member History
Office History
Member Check
Specialist Check
Facility Check
Procedure Look up
Diagnosis Look up
Report Selection
Bulletin Board
Case/Disease Management
Web ROAR Flow
Web Roar Flow
Active Member
Search Window
Diagnosis Code
Search Window
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2a
Request for
Services Window
Specialty
Windows
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Summary/Verification
Window
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ROAR
ConfirmationWindow
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Procedure Code
Search Window
2b
CDM Referral
Entry Window
4a
Fax/Hardcopy
Request Window
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Web ROAR Limitations
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Only Highmark enrollees
Carved Out MRI, Nuclear Cardiology, CT
scans
Primary Care offices – NOT hospitals,
specialists, or ancillary service providers
At Last……Managed Care
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A system of health care delivery that tries to
manage the cost of health care, the quality of
health care, and the access to that care….
Without the wait and paperwork
hassle!!!!!!!!!!