Upload
simon23
View
422
Download
0
Embed Size (px)
DESCRIPTION
Citation preview
Referral and Authorization Process in the Managed
Care Environment
By:Debbie Jankowski
andJoan 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
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 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
The tighter the authorization process the stronger the utilization management by
the payer/plan.
Authorization Types Prospective
Issued before ay service is rendered Concurrent
Allows for timely data collection and the ability to impact the outcome
Retrospective Issued after services are rendered
“Emergency Situations”
Authorization Types (cont.) Pended (for review)
Determine the status of an authorization: Medical necessity Eligibility Administrative review
Denial Subauthorizations
Common with hospital based services(Radiology, Pathology, Anesthesia)
Common Authorization Data Elements
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)
Inpatient data elements Name of institution Admitting physician Admission or service date Diagnosis (ICD-9-CM) Discharge date
Subauthorizations Hospital based providers Other specialists Other procedures/studies
Free text to be submitted to the claims dept.
Methods of Communication Paper-Based System
Pre-printed paper forms through the mail Telephone-Based System
Phone tag, busy signals, waiting on hold Busy fax machines
Electronic System Built in edits on-line Claims submission most common Authorization & Eligibility information available Dedicated lines connected
Problems with Authorization Systems
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” Swiping Card Telephone Entering Number on Keypads
Limited Functionality
Application Service Providers Integration of eligibility, authorization, referrals
Physician Offices and MCOs Cost Savings
Medical Mutual of Ohio – reduce 10-12 FTEs = $600,000.
Time Savings Authorizations from 30 minutes to 10 minutes
Reduction in errors Improved Patient Satisfaction One-Stop-Shopping Diffuse Costs
Regulatory Issues HIPAA – Health Insurance and
Accountability Act Adminitrative Simplification Standardization of Claims/Referral
data Format modified on every 12 Months
Web ROAR ROAR – Referral or Authorization
Request Keystone
Ranked 8th in Nation’s 25 Largest Individual HMO Plans
1,151,224 members (1998)
Web ROAR
Web ROAR Functionality 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 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 FlowWeb Roar Flow
Active Member Search Window
Request for Services Window
Summary/Verification Window
ROAR ConfirmationWindow
Fax/Hardcopy
Request Window
Specialty Windows
Procedure Code Search Window
Diagnosis Code Search Window
CDM Referral Entry Window
2 a
2b
4a
Web ROAR Limitations Only Highmark enrollees Carved Out MRI, Nuclear
Cardiology, CT scans Primary Care offices – NOT
hospitals, specialists, or ancillary service providers
At Last……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….
Without the wait and paperwork hassle!!!!!!!!!!