Presentation on theme: "Referral and Authorization Process in the Managed Care Environment"— Presentation transcript:
1 Referral and Authorization Process in the Managed Care Environment By:Debbie JankowskiandJoan Horen
2 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.
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 SystemHas to define what services require authorization and what do not.Determine who has the authority to authorize services for members:PCPsPlan’s Medical DirectorThe tighter the authorization process the stronger the utilization management by the payer/plan.
5 Authorization Types Prospective Concurrent Retrospective Issued before ay service is renderedConcurrentAllows for timely data collection and the ability to impact the outcomeRetrospectiveIssued after services are rendered“Emergency Situations”
6 Authorization Types (cont.) Pended (for review)Determine the status of an authorization:Medical necessityEligibilityAdministrative reviewDenialSubauthorizationsCommon with hospital based services(Radiology, Pathology, Anesthesia)
7 Common Authorization Data Elements Member’s nameMember’s birth dateMember’s plan identification numberEligibility statusPCPReferral provider’s name and specialtyOutpatient data elementsReferral or service dateDiagnosis (ICD-9-CM)Number of visits authorizedSpecific procedures authorized (CPT-4)
8 Common Authorization Data Elements (cont) Inpatient data elementsName of institutionAdmitting physicianAdmission or service dateDiagnosis (ICD-9-CM)Discharge dateSubauthorizationsHospital based providersOther specialistsOther procedures/studiesFree text to be submitted to the claims dept.
9 Methods of Communication Paper-Based SystemPre-printed paper forms through the mailTelephone-Based SystemPhone tag, busy signals, waiting on holdBusy fax machinesElectronic SystemBuilt in edits on-lineClaims submission most commonAuthorization & Eligibility information availableDedicated lines connected
10 Problems with Authorization Systems Lack of standardization of required information and format between the insurance plansCoordination among the players of the paperworkOngoing changesAdministrative costsDeclining reimbursement
11 IT “Solutions” Swiping Card Telephone Entering Number on Keypads Swiping CardTelephoneEntering Number on KeypadsLimited Functionality
12 Application Service Providers Integration of eligibility, authorization, referralsPhysician Offices and MCOsCost SavingsMedical Mutual of Ohio – reduce FTEs = $600,000.Time SavingsAuthorizations from 30 minutes to 10 minutesReduction in errorsImproved Patient SatisfactionOne-Stop-ShoppingDiffuse Costs
13 Regulatory Issues HIPAA – Health Insurance and Accountability Act Adminitrative SimplificationStandardization of Claims/Referral dataFormat modified on every 12 Months
14 Web ROAR ROAR – Referral or Authorization Request Keystone Ranked 8th in Nation’s 25 Largest Individual HMO Plans1,151,224 members (1998)
16 Web ROAR Functionality Submit referral and authorization requestsVerify patient membershipSearch for specialists, providers, hospitals, or other facilitiesList historical referrals/authorizations for patients or practiceTrack utilization patterns for practice
17 Web ROAR Main Menu Request for Services View Messages Member History Office HistoryMember CheckSpecialist CheckFacility CheckProcedure Look upDiagnosis Look upReport SelectionBulletin BoardCase/Disease Management
19 Web ROAR Limitations Only Highmark enrollees Carved Out MRI, Nuclear Cardiology, CT scansPrimary Care offices – NOT hospitals, specialists, or ancillary service providers
20 Without the wait and paperwork hassle!!!!!!!!!! At Last……Managed CareA 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!!!!!!!!!!