The insurance authorization team was the first department at the VNA to engage in a Plan-Do-Check-Act for process improvement. We began working together on this PDCA in March due to feedback from the team and clinical managers on areas of risk and opportunity they identified within this department.
The primary goal of the insurance authorization team is to obtain timely insurance authorization for patient visits. The team plays a very important role in the delivery of care for our patients as insurance authorization is needed to schedule a patient visit. Clinicians need to have the visit on their tablet so they can see the most up to date information for their patient as well as document at the point of care.
The PDCA addresses the people, processes, and technology within the department. Many great ideas came directly from the authorization team during brainstorming sessions. A few things we have accomplished so far:
- A shift change to 7-3:30 so authorizations can be addressed prior to clinicians starting their day
- Fax line connected to J:drive so authorizations that are returned via fax can be picked up by any member of the team even if working remotely and archived by name.
- Four new hires: two full time team members, 1 per diem team member and a supervisor
- We had four summer interns for temporary support
- Seating changes to support training and team communication
- We are in the process of working with HCHB and element5 to automate workflow
The PDCA is far from over but so far has been effective in improving operations within this department. We hope that everyone is seeing and feeling some improvements in obtaining authorization as the team has made significant strides in catching up and operating in real time.
Now we need your help! To work better together please see the following tips on obtaining insurance authorization:
- Recertification visits must have wound measurements even if wound measurements were just taken at a prior visit. The only exception is for wounds with a non- removable dressing. Insurance companies will not reauthorize further visits without measurements obtained at the actual recertification visit. The authorization team will not be able to move forward in requesting authorization without measurements and this will result in delay of care.
- Ask about change in insurance at every visit.
- Skilled need must be clearly justified at every visit.
- Rehab specific cases – homebound status and skilled need must be clearly indicated when requesting additional visits after more than 8 total therapy visits have been ordered for a patient. Also, make sure there is not duplicate therapy occurring. For example, PT and OT should not be performing /providing the same treatments.
- Turnaround time for additional visits after the original order will take up to 24-48 hours for most insurance plans so plan your visits accordingly. Do not assume they will automatically give authorization.
- Medication set ups must have the corresponding buddy code noted as this delegates the payer that the authorization team needs to reach out to. Not using the buddy code can result in the wrong payer (Medicare) being billed for non-skilled treatment.
- Fidelis – expect 24- 48 hours turnaround time from this payer and do not assume they will authorize additional visits. Plan your visits accordingly.
- Advanced Beneficiary Notices (ABNs) when changing to Medicaid as primary payer – we are no longer able to process insurance changes without physically seeing a signed ABN. A new ABN is required annually.
- Kalos, VNSNY, and Nascentia are Managed Long Term Care Plans. If an insurance change involves changing to one of these plans the clinician must call for authorization. Enter the authorization information into the insurance change note.
- We are not in network with Fallon Heath or Centers Plan and cannot accepts patients that have these plans. If a current patient is changing or has changed to one of these plans, we will have to arrange to discharge from VNA services or patient will incur large expense.