Referral and Authorization Process in the Managed Care Environment

1. Referral and Authorization Process in the Managed Care Environment By: Debbie Jankowski and Joan Horen

2. 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. Definition of Managed Care

3. 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.

4. 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.

5. 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”

6. 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)

7. 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)

8. 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.

9. 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

10. 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

11. IT “Solutions” • Swiping Card • Telephone • Entering Number on Keypads • Limited Functionality

12. 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

13. Regulatory Issues • HIPAA – Health Insurance and Accountability Act • Adminitrative Simplification • Standardization of Claims/Referral data • Format modified on every 12 Months

14. Web ROAR • ROAR – Referral or Authorization Request • Keystone • Ranked 8th in Nation’s 25 Largest Individual HMO Plans • 1,151,224 members (1998)

15. Web ROAR

16. 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

17. 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

18. Web ROAR Flow

19. Web ROAR Limitations • Only Highmark enrollees • Carved Out MRI, Nuclear Cardiology, CT scans • Primary Care offices – NOT hospitals, specialists, or ancillary service providers

20. 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!!!!!!!!!!