Referral%20and%20Authorization%20Process%20in%20the%20Managed%20Care%20Environment

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Referral and Authorization Process in the Managed
Care Environment

• By
• Debbie Jankowski
• and
• Joan Horen

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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.
•  

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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 providers
  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.

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Authorization System

• Has to define what services require authorization
  and what do not.
• Determine who has the authority to authorize
  services for members
• PCPs
• Plans Medical Director
• The tighter the authorization process the
  stronger the utilization management by the
  payer/plan.

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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

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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)

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Common Authorization Data Elements

• Members name
• Members birth date
• Members plan identification number
• Eligibility status
• PCP
• Referral providers name and specialty
• Outpatient data elements
• Referral or service date
• Diagnosis (ICD-9-CM)
• Number of visits authorized
• Specific procedures authorized (CPT-4)

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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.

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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

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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

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IT Solutions
 

• Swiping Card
• Telephone
• Entering Number on Keypads
• Limited Functionality

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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

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Regulatory Issues

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

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Web ROAR

• ROAR Referral or Authorization Request
• Keystone
• Ranked 8th in Nations 25 Largest Individual HMO
  Plans
• 1,151,224 members (1998)

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Web ROAR
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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

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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

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Web ROAR Flow
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Web ROAR Limitations

• Only Highmark enrollees
• Carved Out MRI, Nuclear Cardiology, CT scans
• Primary Care offices NOT hospitals,
  specialists, or ancillary service providers

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At LastManaged 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!!!!!!!!!!