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Charting your patients' insurance: It's all in a simple grid

With one sheet of paper, a suburban Chicago practice found a way to navigate the maze of insurers' requirements for referral and reimbursement.

By Emily Berry — Posted Feb. 25, 2008

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Like fighting fire with fire, Vista Family Medicine fights paperwork with paper. As many practices do, Vista struggles with tracking the ever-changing rules and requirements of multiple insurers, with multiple plans offered by each.

Asking patients to know what's covered by their insurance wasn't going to solve the problem, because even if a patient claimed to know, the rules might have changed since the last visit.

So Vista, located in an office building attached to a hospital in the southwest Chicago suburb of Evergreen Park, put together a horizontal, 8½- by 11-inch, frequently updated quick reference sheet called the "Insurance Grid."

Even though the office has a computerized practice management and electronic medical records system, it has found that using the one-page grid, posted in the front-office area and the six exam rooms in the two-physician practice, was the quickest way to check the rules of insurance for its 3,000 patients.

The columns and rows in the insurance grid outline insurers' preauthorization requirements for diagnostic imaging, referrals to specialists and laboratory testing.

The grid doesn't make dealing with health plans pain-free. It is more like armor worn in a lengthy battle.

Even if the practice knows whom to call and what to ask for, staff and physicians still must spend hours on the phone or online asking for permission to order MRIs, lab tests or specialist consults.

But Vista's founding physician, Jim Valek, MD, said the grid does save him, his staff and his patients from wasting time on checking or arguing over coverage.

Jeff Sinaiko, president of Los Angeles-based Sinaiko Healthcare Consulting, said staying on top of insurers' rules is vital to a well-run practice.

"In the end, the whole point of this is to try to make the processes of providing services and getting paid for them as efficient as possible," he said. "One of very common findings we have in looking at clients who may be struggling to collect their accounts receivable is [a high] number of services denied because of lack of authorization numbers. The cost of failing to execute this process well is significant."

Vista is in the minority of practices in the way it proactively manages pre-authorization requirements, said Rick Langosch, a manager, consultant and chief financial officer for suburban Atlanta-based Coker Group, a health care consulting firm.

He estimated that less than 20% of practices actually take the time to organize and keep track of health plans' requirements. "They usually just go through the mechanism for billing, wait for it to come back [denied], and take it as it comes back to them rather than being proactive," he said.

Saving time

To ensure that the grid remains useful, Vista's practice manager, Sue Sarhage, updates the insurance grid, whose master copy is a Microsoft Excel file, as often as once per month.

Health plans typically send e-mails to alert the practice to rule changes, she said.

"At first we had it laminated and everything, but then we found we were changing it so much," Sarhage said.

Having the rules summarized and posted saves five to 10 minutes for a patient each time a physician needs to make a referral and probably an hour per day in physician time, she said.

Requirements for ordering laboratory tests, specialists and other radiology tests vary from all-electronic pre-authorization systems to simple prescriptions and permission to do in-office testing.

Some insurers allow electronic approvals; some require a phone call; some require a form faxed to one of the imaging approval companies.

And the rules change on a regular basis.

As of January, Vista accepted 12 plans offered by WellPoint, Humana, BlueCross BlueShield of Illinois, Private Health Care System (PHCS), Aetna and Cigna, with eight sets of rules.

Most plans run their pre-authorization for MRI, CT and PET scans through one of three companies -- American Imaging Management, HealthHelp or MedSolutions.

Both Dr. Valek and Sapana Rana, DO, Vista's two physicians, said they usually can remember the rules for the most common referrals under the most common plans, but they do use the grid on a regular basis, as do the practice's four medical assistants.

Often, both doctors said, patients have no idea what their insurance coverage is, so it falls to the physicians or staff to figure out what is covered and what is not. "The insurers are happy to dump the patient education portion of their business on physicians," Dr. Valek said.

Dr. Rana said that between 20% and 30% of her patients need some kind of follow-up care that will mean consulting the grid or recalling what's on it.

One case in January involved a 15-year-old boy who was having frequent and worsening headaches. Because of a family history of brain tumors, his mother brought him in to see if further testing was warranted.

Dr. Rana wanted to order a CT scan to rule out cancer.

The family was enrolled in an HMO, so a referral would be necessary, Dr. Rana said, but she didn't have to check the grid because the HMO is sponsored by Advocate Health Care, a Chicago-area integrated care delivery network that is common among Vista's patients.

Dr. Rana told the boy and his mother what she wanted to do and that it would require a pre-authorization from their HMO.

She noted a referral diagnosis on his chart, and when the exam was over, she handed it to a medical assistant and asked her to print out the referral and call for prior authorization.

The boy and his mother sat in the waiting room for a few minutes while the medical assistant printed Dr. Rana's referral, and after they left she filed an electronic request for pre-authorization through the family's HMO.

If a patient's insurer is less familiar, Dr. Rana said, she does consult the grid in the exam room. If a patient has a question about a difference in cost or whether they might be allowed to have their test done at a particular place, she said she refers them to a medical assistant or to billing staff.

If a certain test is denied, or the out-of-pocket expense is too high, she does sometimes try to find a less costly alternative, she said.

Sarhage said that although figuring out what's required to order specific tests is a shared responsibility, ultimately the medical assistants must know what's needed and help ensure the test is approved and documented.

Some doctors would balk at thinking about patients' care in terms of their insurance coverage, but Dr. Valek said it's become a necessary evil. He estimated that he spends an hour of each day dealing with referral requirements, so he must keep in mind when he talks to a patient what tests are covered, what requires pre-approval and what does not.

"It just gets more and more more complex every year," he said.

The grid isn't by any means the only quick-reference guide in the office. There are also a couple of big binders where medical assistants and physicians can go to decode insurers' rules and guidelines. And the walls also are covered with lists of commonly dialed fax numbers, charts showing recommended immunization schedules, and calendars galore.

The next step may be to hire more staff to help carry the load, Sarhage said.

"It seems like all of these insurance companies have grown so much and so quickly, there's no direction," Sarhage said. "What I'm finding is everyone is trying to cope with these changes, but unless you have a mother hen at each practice saying, 'We're going to a have a plan,' I see a lot of administrators really floundering trying to get on top of these rulings and specifications."

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ADDITIONAL INFORMATION

Tracking the rules

Here are some tips from practice management experts for keeping track of health plans' pre-authorization requirements for imaging, lab tests and referrals:

  • Create a reference sheet and a more detailed reference binder for multiple managed care contracts. Update both regularly.
  • Put a few staff members (more than one, so they can cover for each other during vacations and sick days) in charge of pre-authorizations and referrals. Then they can track rule changes, complete needed referral paperwork and answer other staff members' questions.
  • Periodically audit your accounts receivable to track the frequency of denials based on lack of pre-authorization. You may notice a pattern and catch an overlooked rule or change in requirements.
  • If you can't get a handle on your pre-authorizations and referrals in-house, consider outsourcing your billing and claims administration to a company that handles claims start to finish.

Sources: Sue Zumwalt, practice manager at Pediatric Associates of Stockton (Calif.), member of the Professional Assn. of Health Care Office Management; Rick Langosch, Manager, consultant and CFO, the Coker Group; Jeff Sinaiko, President, Sinaiko Healthcare Consulting

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